By Sean Kirby
Just about everyone has that friend or family member who invites you out to a nice dinner. Then, when the check is about to come, they conveniently excuse themselves to go to the washroom, say they only have a $100 bill or find some other excuse to stick you with the entire cost of the meal.
That scenario is getting ready to play itself out soon on a much larger scale with hospitals and COVID-19. Currently, hospitals and other care facilities are doing all they can (and rightfully so) to treat patients who have acquired the virus as well as prepare for any future surges. In some cases, especially in hot spots, the volume of patients means temporarily setting aside best practices to deal with issues such as a shortage of personal protective equipment or taking other shortcuts.
Even the normally rigid Centers for Medicare and Medicaid Services (CMS) has taken steps such as loosening its restrictions around payment for telehealth to ensure patients and providers remain safe while needed care is delivered. That is not unusual in the midst of an event that has fundamentally changed so many lives throughout the world. You tend to do whatever is needed at the time to deal with the crisis.
Yet one day, hopefully in the not-too-distant future, the COVID-19 pandemic will transition from current event to history. At that point, just like in the restaurant, the bill for all this unprecedented care and effort will come due. That’s why hospital administrators need to act now to ensure that when it does, they don’t get stuck with the entire check.
One of the most important steps they can take is to ensure that all their COVID-19-related care is being properly coded. Hospitals are already losing significant revenue during this pandemic as a result of canceling elective surgeries and other reductions in their major revenue streams. Proper coding will ensure it doesn’t slip even further.
Of course, if it were that easy everyone would already be doing it. To ensure full reimbursement, providers must use the new, COVID-19-specific CPT codes CMS has designated (rather than existing codes for flu, pneumonia, etc.) when documenting applicable care.
By following these steps, healthcare executives can help avoid their organizations being left with the check once the COVID-19 pandemic is past.
- All charges from the hospital or physicians billing system should be queried, beginning from March 1, 2020. Look for records that say the patient was tested for COVID-19 as well as those that say the test was positive. The coding should align with that information. If it does not, the coding should be corrected before submission.
- Look at HCPCS code U0002 at the detailed charge level to find all the COVID-19 tests reported from non-CDC labs since their reimbursement levels are higher than CDC labs. Simply saying “COVID-19” testing will likely result in reimbursement at the lower level.
- CPT code 87635 should be used when COVID-19 and/or any pan-coronavirus types or subtypes are detected. This is important because while the media often uses “COVID-19” and “coronavirus” to mean the same thing, the former is a subset of the latter. If you are testing for the strand of coronavirus that is specific to COVID-19 the coding must indicate this fact if full reimbursement under the various relief packages is to be achieved. It is also possible that if COVID-19 persists into 2021 there could be a new strand which will have its own code. Building a habit of specificity is critical to realizing full reimbursement.
- Be sure to keep up with new CMS updates such as the three newly release CPT codes for COVID-19 on July 8, 2020 that will be retroactive to June 25, 2020. They are:
- 87426, CORONAVIRUS AG IA
- 0223U, NFCT DS 22 TRGT SARS-COV-2
- 0224U, ANTIBODY SARS-COV-2
- Daily instances of testing should be monitored to ensure proper coding and billing are prepared for the volume of new cases. It is important to track which patients are coming to the hospital for first-time testing versus those who are returning after a previous test, as there will be different procedures and reimbursement schedules for each. Ensuring that lab results are reliable and that the facility has a sufficient supply of tests to meet the demand is also critical not just to quality care but also to maximizing revenue.
- Review all documentation prepared before April 1, 2020 – the point when CMS began accepting new codes – to ensure it is accurately coded. Prior to this date, local payers may have had different reporting requirements. A review of the documentation from earlier in the year will confirm whether it meets current standards.
- Connect the dots between patients who are tested for COVID-19 and those who are admitted to the hospital. Patients with positive tests will have more complications than those with pneumonia or a standard flu, may require special equipment such as ventilators and will likely have secondary or tertiary diagnoses as well. To receive full reimbursement, all of these conditions must be documented and accurately coded. Special attention should be given to finding patients who were admitted to the hospital for other issues and then diagnosed with COVID-19 because their now-elevated risk could easily be missed when billing. Hospitals don’t want to treat a complex COVID-19 patient while being reimbursed for a lesser level of care. The documentation must align to the proper level of diagnosis to avoid that situation.
These are the key steps for the current state. Of course, our understanding of COVID-19 is constantly evolving, which mean more changes could be on the way. For example, with new information that the virus’ origin could date back to November or December, it is possible that patients who were diagnosed with flu or pneumonia during that timeframe may have actually had COVID-19 instead.
With that in mind, hospitals will want to keep samples from earlier months to prepare for the possibility they can be retro-tested and re-coded sometime in the future. Without those samples they will not be able to increase reimbursement to reflect the level of care delivered.
When the focus is on saving lives and providing comfort in a fast-moving, devastating situation, it is understandable that documentation and coding may not top-of-mind. But eventually the check will come due. By improving the accuracy of documentation and coding now, hospitals can avoid getting stuck with it themselves.
Sean Kirby is SVP at VisiQuate.
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