CMS To Require Proof of Positive COVID-19 Test To Get 20% MS-DRG Bonus

In an Aug. 17 MLN Matters article, CMS stated that starting September 1, hospitals will lose the 20% Medicare bonus for treating inpatients with Covid-19 unless there’s proof of a positive Covid-19 lab test. Physicians and health systems should be aware that a presumptive positive test based on the physician’s diagnosis of a patient’s symptoms will no longer meet the requirements to receive the bonus.

In order to continue to be eligible for the 20% bonus after September 1, you must meet the following CMS requirements:

  • The positive test result must be documented in the medical record
  • Providers must use a viral test such as a molecular or antigen test that is consistent with the Centers for Disease Control and Prevention guidelines
  • Testing must be done upon hospital admission or within 14 days prior to the admission (If a test is performed more than 14 days prior to a hospital admission, CMS will consider if there are medical factors in addition to that test result to determine whether the documentation requirement has been fulfilled.)
  • If the test is not performed at the hospital, the results should be manually entered into the patient’s medical record in order to satisfy the requirement

CMS issued the new requirement in an effort to combat fraud related to Covid-19 admissions. Hospitals could face post-payment reviews and compliance risk. The new guidance comes amid testing delays in areas with higher infection rates.

You can read more about the new guidance here:

HBE’s team of coding and compliance experts is available to assist you with evaluating your documentation and coding, review and development of policies and procedures, as well as providing customized education and training for your staff. 

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