CMS revises billing instructions for inpatient COVID-19 claims

CMS provided clarification on submitting inpatient claims for patients diagnosed with novel coronavirus (COVID-19) without a positive viral test, in an update to MLN Matters SE20015 released September 11.

Earlier this year, the CARES Act increased the MS-DRG weighting by 20% for a COVID-19 diagnosis. Although the CARES Act doesn’t specify that the diagnosis must be supported by a positive test result, CMS updated SE20015 in August to say that a positive viral test result would be required to qualify for the increased MS-DRG payment, effective for admissions on or after September 1. The test must be performed within 14 days of admission, and the results must be documented in the patient’s medical record.

If a patient is diagnosed with COVID-19 consistent with the ICD-10-CM guidelines but does not have a positive viral test result, the hospital may decline the additional MS-DRG payment at the time of claim submission. The hospital must inform its Medicare Administrative Contractor (MAC) of its intent to decline, and the MAC will then apply its internal claim processing coding to the claim.

The September 11 update to SE20015 clarifies the process for notifying MACs. To notify their MACs that there is no positive test result in the medical record for a COVID-19 claim, hospitals should enter a Billing Note NTE02 “No Pos Test” on the electronic claim 8371 or a remark “No Pos Test” on paper claims.

Hospitals should ensure billing staff and other revenue integrity and revenue cycle staff are aware of the updated instructions. Hospitals can contact their MAC with specific questions

Editor's note: A version of this article originally appeared on Revenue Cycle Advisor..