By Nancy Hirschl, BS, CCS, AHIMA-Approved ICD-10 Trainer
Vice President, HIM & Product Strategy
With the dramatic onset of the COVID-19 pandemic, CMS issued brand new ICD-10-CM codes to identify and reimburse COVID-based encounters, along with new—and subsequently adjusted— rules for using them. The sequence below captures the complexity of this unprecedented scenario from a medical coding perspective:
- For COVID-related discharges/encounters occurring on or after January 27, and on or before March 31, medical coders for providers (both hospitals and physicians) were instructed to assign ICD-10-CM diagnosis code B97.29, Other coronavirus as the cause of diseases classified elsewhere as a secondary diagnosis. Codes for the COVID-related conditions such as pneumonia, bronchitis or ARDS were to be assigned as principal or first-listed diagnosis code.
- On February 20, WHO presented a new ICD-10 Code (U07.1, 2019-nCoV acute respiratory disease) for COVID-related care.
- On April 1, CMS issued unprecedented regulatory guidance for coders/providers to report COVID-19 using ICD-10-CM code U07.1. The new guidelines state that the provider should “Code only a confirmed diagnosis of the 2019 novel coronavirus disease (COVID-19) as documented by the provider, documentation of a positive COVID-19 test result, or a presumptive positive COVID-19 test result. This is an exception to the hospital inpatient guideline Section II, H.”
- On April 15, 2020, CMS published an update that notified hospitals that any encounter where COVID-19 was reported using code U07.1 would receive a 20% increase in DRG reimbursement.
For providers attempting to accurately code and be properly reimbursed for these encounters, the sequence here exposes a truly daunting task:
- Starting April 1, code B97.29 will not generate the correct DRG and associated reimbursement nor the corresponding 20% DRG payment increase
- Encoders may not be providing Date of Service (April 1, 2020) edits/flags regarding the new parameters yet
- Coding Clinic Guidelines are issued quarterly, so coders may not have access to latest regulations
Unfortunately, this represents a ‘perfect storm’ scenario for provider organizations. Operations have been dramatically impacted, staff member’s lives are undergoing tremendous change, and for this sudden surge of COVID-related care, getting accurately reimbursed requires coding staff to single-handedly navigate these complex requirements. Factor in the rising costs and the drop in higher revenue-generating procedures, and this is truly a recipe for financial disaster.