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.