2.1 Temporary
Diagnosis Related Group (DRG) Adjustment for Individuals Diagnosed
with 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 demonstrate positive tests
by using results consistent with Centers for Disease Control and
Prevention (CDC) guidelines. The contractor shall only reimburse
for tests 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
shall multiply the current Medicare Severity (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 The contractor
shall exclude all hospitals that are exempt from the IPPS DRG system,
including hospitals in Maryland, 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 The contractor
shall exclude all LTCHs that are exempt from the LTC-PPS MS-LTC-DRG
system from this policy.
2.3 Skilled
Nursing Facility (SNF) Three-Day Prior Hospital Stay Requirement
The contractor shall waive
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) for the duration of
the President’s national emergency for the COVID-19 outbreak.