Coders Adapt to COVID-19 Sequencing That's a 'Departure'; Brace for Denials of 20% Bonus

Assigning the principal diagnosis in a COVID-19 world and protecting claims from downcoding by Medicare, Medicare Advantage (MA) and commercial payers has become more complicated. Hospitals are now advised to code COVID-19 as the principal diagnosis when patients are admitted with conditions associated with COVID-19, with some exceptions, including sepsis. But payers may remove sepsis diagnoses from claims inappropriately, experts say, which will affect reimbursement differently this year versus last year—more if patients were on a ventilator. On a related note, effective Jan. 1, there are new diagnosis codes for more specific manifestations of COVID-19, including COVID-19 pneumonia.

“You want to make sure you’re watching very carefully,” said Garnette McLaughlin, senior consultant and compliance officer at Intersect Healthcare + AppealMasters in Towson, Maryland. “Watch the date of services to make sure you’re using the right codes.”

Meanwhile, hospitals should be on the lookout for denials of the 20% bonus on their claims for treating COVID-19 inpatients or MA plan withholds. One hospital in late January had the money held back by an MA plan that selectively applied the policy implementing the Coronavirus Aid, Relief, and Economic Security (CARES) Act’s increase in the MS-DRG relative weight, said Richelle Marting, an attorney for the hospital. She thinks this will be a fertile area for denials.

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