CMS to Require Positive COVID-19 Test Results for 20-Percent Medicare Add-on Payment

EDITOR'S NOTE: This story was published Aug. 1, 2020 on RACmonitor and is being published here today on ICD10monitor and BC Advantage Magazine, given its importance and timeliness.

The Centers for Medicare & Medicaid Services (CMS) started rolling out post-payment audits again, as of Aug. 3, but now - after finding inconsistencies in the accuracy of some COVID-19 tests, and considering the fact that CMS has been paying an additional 20 percent to providers and facilities "treating patients with COVID or testing for COVID" - the agency has enacted a new mandate to qualify for the increased reimbursement.

Starting today, CMS is requiring hospitals to have positive COVID-19 laboratory tests in patients' records to qualify for the add-on payment.

The new mandate (read it online at, which CMS said seeks to address "potential Medicare program integrity risks," applies to admissions beginning tomorrow, Sept. 1. Until now, CMS guidance has indicated that a provider's documentation – but not necessarily a positive test result – is sufficient to receive the 20-percent higher Medicare reimbursement for inpatient COVID treatment.

CMS has also said they will continue to apply the 20-percent add-on payment for COVID-19-related claims after the final rule takes effect, but they added that there will be post-payment audits/reviews to enforce this requirement – and sort of post-oversight, if you will, with the extra 20 percent to be recouped if no positive test results are found.

What will no doubt be a problem here, not only from the standpoint of administrative burden on hospitals and physician practices, is the fact that COVID-19 tests have become more widely available, and many hospital systems have treated thousands of patients who may have tested positive at some point during the pandemic. Yet in many cases, those patients then had several repeated tests, only to get a negative result, or repeated tests if initially testing positive despite being asymptomatic.

CMS is now in the later stages of this process, and hopefully heading towards the post-pandemic era, while seeking to make sure that patients are not being "labeled" or diagnosed with COVID-19 when they did not test positive or were not treated for COVID. In such a scenario, a diagnosis or -CS modifier being added to a claim to receive the added 20-percent payment would be fraudulent.

The American Hospital Association (AHA) is asking CMS to reconsider the new requirement. The lobbying group contended in a letter sent to CMS Administrator Seema Verma on Wednesday that requiring test results would put a "substantial administrative burden" on hospitals, asserting that provider documentation should continue to suffice. Their argument fell back on the CDC ICD-10 Coding advice that "the COVID-19 diagnosis code on clinical judgment alone – in line with coding rules – continues to be an important approach, given that test accuracy may not be reliable, retesting is unnecessarily onerous, and some communities face persistent testing shortages," according to Ashley Thompson, the AHA's senior vice president of public policy analysis and development.

The problem CMS is also finding is that in addition to a provider's confirmation, hospitals have until now been able to use state or local COVID-19 test results, even if they weren't confirmed by the Centers for Disease Control and Prevention (CDC), to get the 20-percent add-on payment. That will no longer fly. CMS now requires viral testing – meaning molecular or antigen testing – consistent with CDC guidelines.

The two International Classification of Diseases, 10th revision (ICD-10-CM) codes used to identify COVID patients are U07.1 for discharges on or after April 1, and, before that, B97.29 for discharges on or after Jan. 27.

CMS implemented the provisions of Section 3710 of the Coronavirus Aid, Relief, and Economic Recovery (CARES) Act in CR 11764:

"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 MS-DRG weighting factor will also 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.

For this purpose, a viral test performed within 14 days of the hospital admission, including a test performed by an entity other than the hospital, can be manually entered into the patient's medical record to satisfy this documentation requirement. For example, a copy of a positive COVID-19 test result that was obtained a week before the admission from a local government-run testing center can be added to the patient's medical record. In the rare circumstance where a viral test was performed more than 14 days prior to the hospital admission, CMS will consider whether there are complex medical factors in addition to that test result for purposes of this documentation requirement", The new rule goes on to say, "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."

The AHA went on to argue that in some cases, hospitals might have to dedicate considerable time and effort trying to get test results from third-party providers and manually enter them into their medical records. The question is, will hospitals ultimately have to retest patients if they can't obtain the results? Would these tests be covered? There is no medical necessity for retesting for administrative reasons.

What my concern is, from a compliance and honesty and financial perspective, will we all of a sudden start to see a surge in "positive tests," because that is the only way, as of Sept. 1, to get the additional 20-percent payment from Medicare? The rule did not just say "test results;" it said "positive" test results. CMS wants to make sure that patients not having to pay their share of cost are true "COVID-19" patients, and that their efforts to ease financial burdens for COVID patients are fruitful.

Post-event oversight is hard to implement. This will be a story to keep an eye on in the coming months, so stay tuned.

Programming Note: Terry Fletcher is a member of the ICD10monitor editorial board and is a popular panelist on ICD10monitor podcast, Talk Ten Tuesdays. Listen to her report this story live during Talk Ten Tuesdays at 10 a.m. EST.

Terry Fletcher, BS, CPC, CCC, CEMC, CCS, CCS-P, CMC, CMSCS, CMCS, ACS-CA, SCP-CA, QMGC, QMCRC, is a healthcare coding consultant, educator, and auditor with more than 30 years of experience. Terry is a past member of the national advisory board for AAPC, past chair of the AAPCCA, and an AAPC national and regional conference educator. Terry is the author of several coding and reimbursement publications, as well as a practice auditor for multiple specialty practices around the country. Her coding and reimbursement specialties include cardiology, peripheral cardiology, gastroenterology, E&M auditing, orthopedics, general surgery, neurology, interventional radiology, and telehealth/telemedicine. Terry is a member of the ICD10monitor editorial board and a popular panelist on Talk Ten Tuesdays.