2.1 Temporary
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. The contractor shall instruct
the provider to demonstrate positive tests using
results consistent with Centers for Disease Control and Prevention
(CDC) guidelines. The contractor shall instruct the
provider to perform the test 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 shall 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. The
contractor shall not adjust a hospital’s capital
IPPS payment.
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
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
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.