2.1 Temporary
Diagnosis Related Group (DRG) Adjustment for Individuals Diagnosed
with Coronavirus or COVID-19
2.1.1 The
contractor shall apply a 20% adjustment factor to increase the DRG
relative weight that would otherwise be applied when determining
Inpatient Prospective Payment System (IPPS) operating payments for
discharges described below, effective for claims with an admission
date occurring on or after January 27, 2020, through the end of
the emergency period.
2.1.2 Section
3710 of the CARES Act directed the increase of the weighting factor
of the assigned DRG by 20% for an individual diagnosed with COVID-19
discharged during the COVID-19 Public Health Emergency (PHE) period.
The contractor shall identify discharges of an individual diagnosed
with COVID-19 by the presence of the following International Classification
of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) diagnosis
codes:
• B97.29
(Other coronavirus as the cause of diseases classed elsewhere) for
discharges occurring on or after January 27, 2020, and on or before
March 31, 2020.
• U07.1 (2019-nCoVacute respiratory
disease) for discharges occurring on or after April 1, 2020, through
the duration of the COVID-19 public health emergency period.
2.1.3 The
contractor shall ensure that for admissions occurring on or after
September 1, 2020, claims are only eligible for the 20% adjustment
factor if a positive COVID-19 laboratory test is documented in the
patient’s medical record. Positive tests shall be demonstrated using
results consistent with Centers for Disease Control and Prevention
(CDC) guidelines. The test shall be performed either during or prior
to the hospital admission.
2.1.4 The
contractor may conduct a 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 contractor shall
recoup the additional payment resulting from the 20% adjustment
factor.
2.1.5 The
contractor will multiply the current MS-DRG relative weight for
the discharge by a factor of 1.20 when calculating a hospital’s
operating IPPS payment. Section 3710 of the CARES Act amended Section
1886(d)(4)(C) of the Social Security Act which generally governs
IPPS operating payments. A hospital’s capital IPPS payment shall
not be adjusted.
2.1.6 The
contractor shall determine high cost outlier payments for IPPS discharges
during the emergency period with a COVID-19 diagnosis code after
applying the increased payment under section 3710 of the CARES Act.
2.1.7 All hospitals that are exempt
from the IPPS DRG system, including hospitals in Maryland, are excluded
from this policy.
2.2 Long Term Care Hospital (LTCH)
Reimbursement
2.2.1 The contractor shall pay all
LTCH cases admitted during the COVID-19 PHE period the LTCH PPS
standard Federal rate, effective for claims with an admission date
occurring on or after January 27, 2020, through the end of the emergency
period. Section 3711(b)(2) of the CARES Act provides a waiver of
the application of the site neutral payment rate under Section 1886(m)(6)(A)(i)
of the Act for those LTCH admissions that are in response to the
PHE and occur during the COVID-19 PHE period. For details on LTCH
reimbursement, see
Chapter 16, Section 1.
2.2.2 All LTCHs
that are exempt from the LTC-PPS MS-LTC-DRG system are excluded
from this policy.
2.3 Skilled Nursing Facility (SNF)
Three-Day Prior Hospital Stay Requirement
The requirement for a qualifying
hospital stay of three consecutive days or more, not including hospital
discharge day, prior to SNF admission (see
Chapter 8, Section 2)
is waived for the duration of the President’s national emergency
for the COVID-19 outbreak.