The Centers for Medicare & Medicaid Services (CMS) updated its April guidance regarding the implementation of section 3710 of the Coronavirus Aid, Relief, and Economic Security (CARES) Act for inpatient prospective payment system (IPPS) hospitals.
To address potential Medicare program integrity risks, effective with admissions occurring on or after September 1, 2020, claims eligible for the 20 percent increase in the Medicare Severity-Diagnosis Related Group (MS-DRG) weighting factor will be required to have a positive COVID-19 laboratory test documented in the patient’s medical record. Positive tests must be demonstrated using only the results of viral testing (i.e., molecular or antigen), consistent with CDC guidelines. The test may be performed either during the hospital admission or prior to the hospital admission.
CMS may conduct post-payment medical review to confirm the presence of a positive COVID-19 laboratory test and, if no such test is contained in the medical record, the additional payment resulting from the 20 percent increase in the MS-DRG relative weight will be recouped. A hospital that diagnoses a patient with COVID-19 consistent with the ICD-10-CM Official Coding and Reporting Guidelines but does not have evidence of a positive test result can decline, at the time of claim submission, the additional payment resulting from the application at the time of claim payment of the 20 percent increase in the MS-DRG relative weight to avoid the repayment.
A Medicare Learning Network article with the updated guidance is available here. For information specific to what CMS is doing in response to COVID-19, please visit the Current Emergencies Website.