OIG to Audit Medicare Payments for COVID-19 Discharges

September 09, 2020 - HHS’ Office of the Inspector General (OIG) will audit Medicare payments made to hospitals for COVID-19 discharges that qualified for a 20 percent add-on payment under the Coronavirus Aid, Relief, and Economic Security (CARES) Act, according to a new item on the agency’s work plan.

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The item put on the OIG’s work plan in August 2020 stated that the agency will “audit whether payments made by Medicare for COVID-19 inpatient discharges billed by hospitals complied with Federal requirements.”

OIG plans to release a report detailing its findings in the 2022 fiscal year.

The agency also reported earlier in the month that it will audit the $50 billion coronavirus relief funds given to healthcare providers through the Provider Relief Fund.

As part of the financial aid offered to healthcare providers during the public health emergency, the CARES Act passed in March 2020 directed HHS to increase the weighting factor of the assigned Diagnosis-Related group by 20 percent for discharges of individual diagnosed with COVID-19 during the emergency period.

Discharges eligible for the add-on Medicare payment were identified by the presence of the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) diagnosis codes B97.29 or U07.1.

But recently, CMS updated the Medicare billing requirements for the 20 percent add-on payment to include a positive COVID-19 laboratory test.

The update communicated in a MLN Matters article last month stated that admissions occurring on or after September 1, 2020, would need to have a positive COVID-19 laboratory test documented in the patient’s medical record in order to qualify for the add-on payment.

Claims that cannot support a COVID-19 diagnosis with a positive laboratory test within 14 days of hospital admission may be subject to post-payment review and potential payment recoupment, according to CMS.

The agency said it enacted the new requirement to protect Medicare program integrity.

These changes, however, have not helped providers understand how to correctly code and bill for COVID-19 care.

A recent survey of healthcare CFOs and revenue cycle leaders found that confusion around COVID-19 coding and claim requirements was one of the top impacts of COVID-19 on the revenue cycle, second only to erratic claim volumes.

The COVID-19 pandemic has been an unprecedented event for the healthcare industry and leaders have had to quickly develop coding and billing guidelines to help providers navigate the complicated process or getting paid for the treatment of patients with a novel virus.

This has led to a barrage of new policies and standards, as well as frequent updates to policies released at the start of the pandemic.

In this type of environment and with the no real end in sight for COVID-19, documentation is becoming even more important for healthcare providers looking to get paid for treating COVID-19 patients.

“There's a lot of confusion over what the blanket waivers cover versus what happens under specific waivers versus what governors are stating,” says Delphine O’Rourke, who currently serves as a partner at Goodwin and has previously worked for Duane Morris and Ascension. “We find in emergencies, that for months and years afterward, you are dealing with payment and insurance issues.”

“This needs to be documented,” O’Rourke stressed in an interview with RevCycleIntelligence at the start of the pandemic.

The advice still rings true considering persistent confusion around COVID-19 coding and billing.

Comprehensive clinical and financial documentation can help providers support their actions during the public health emergency and avoid potential payment recoupments from the audits that will start to happen.