In the early stages of the pandemic, CMS guidance indicated that a provider's documentation was sufficient to receive reimbursement from payers. The 20‐percent higher Medicare reimbursement for inpatient COVID treatment and a positive test result was not necessary. However, effective September 1, 2020, CMS has enlisted a mandate requiring hospitals to have positive COVID‐19 laboratory tests in patients' records to qualify for Medicare's 20‐percent add‐on payment. Suffice it to say, ensuring appropriate reimbursement for COVID-19 claims require careful management and attention to detail.
COVID-19 descended upon us without much warning. There have been many changes in regards to coding guidelines and the charging stipulations around the treatment of COVID, creating a source of concern for healthcare organizations, on several levels, particularly around the documentation of the treatment of COVID related to proper reimbursement.
There are certain areas of focus that offer a tremendous opportunity for a healthcare organization to ensure proper reimbursement and prevent revenue from going unclaimed, in particular as it relates to COVID testing and treatment, specifically in cases where the cost sharing modifier or the Cost Sharing (CS) Modifier is required.
This can be significant, as it is an opportunity to capture more reimbursement, it also poses an increased probability for external audits. For example, a patient that is seen and tested for COVID with a positive result or receives treatment for COVID related signs and symptoms an Evaluation Management code may be present assuming it took place in an outpatient setting.
A case with an Evaluation Management Code presented without the CS Modifier would create a scenario in which the claim would be subject to certain stipulations, such as a limited amount from the payor or possibly an additional co-pay will be required from the patient. However, with a CS Modifier, if appended to that Evaluation and Management code, in that event, the payor would be responsible for 100% of the cost. This applies to not only Medicare or Medicaid claims but any payer according to COVID-19 regulations.
Though these types of instances open up an opportunity for an organization to ensure they are paid all the dollars they are due, there is also a flip side as this poses an increased chance of an external audit. Auditors can look at the volume of CS modifiers being used, as it is discreet data that is appended on the Evaluation and Management code. If it shows to be a higher volume than other peer groups, it may likely prompt questions.
Providers pinpoint where the breakdown can occur and adjust processes:
To resolve the reimbursement risk and address possible external audit inquiries, a custom edit can be put in place for tracking and auditing these claims to ensure appropriate coding, charging and reimbursement. The high volume of these tests, along with the blanket coverage of the services related to this virus, and variance in guidelines opens the door to errors. It is imperative to explore the opportunities available through preventive action to create clean claims and reduce denials' incidence. Take into account all the details to be assimilated, and establish a plan that will safeguard your organization's reimbursement and mitigate the risk of revenue loss associated with the testing and treatment for COVID-19.
For further information on the Waivers and Provisions of the CARES ACT related to COVID-19 Testing and Treatment, visit the CMS website here https://www.cms.gov/files/document/se20015.pdf
Axea Solutions Advisors are available for support and can provide guidance as changes continue to evolve. For more information or to access Axea advisory services, please contact an Axea representative.