By SEAN KIRBY
Right now, hospitals and other care facilities (especially those in “hot spots”) are pulling out all stops to treat patients who have acquired COVID-19 as well as to plan for any future surges – even if it means taking some shortcuts or temporarily setting aside best practices to address issues such as a shortage of personal protective equipment.
The Centers for Medicare and Medicaid Services (CMS) has gotten on-board, relaxing its rules around payment for telehealth in an effort to deliver the care that’s needed while keeping people safer.
This is what tends to happen when you’re in the middle of a life-changing global event. The focus will always be on addressing the immediate crisis through any means necessary.
Yet one day, hopefully in the not-too-distant future, the COVID-19 pandemic will be behind us and the bill for all this extraordinary care will come due. And like cleaning up after the circus leaves town, it has the potential be a most unpleasant job.
That is, unless hospital administrators take steps now to ensure that care is carefully coded. Proper coding is the key to avoiding taking a significant revenue hit later to add on to the money they've already lost by canceling elective procedures and reducing their other major revenue streams.
On the surface, the process appears to be straightforward. CMS has issued new CPT codes for COVID-19, so providers must ensure they are using those codes (versus, for example, existing codes for flu or pneumonia) if they want to be fully reimbursed for treating COVID-19 patients. Yet nothing is simple when it comes to healthcare billing.
With that in mind, here are the steps healthcare executives need to follow to ensure they’re not left holding the broom.
- Query all charges from the hospital or physicians billing system starting in March 2020. If the record says the patient was tested for COVID-19, found positive, etc. the coding should reflect that. If the coding is incorrect, it should be changed to the accurate code before submitting it.
- At the detailed charge level, identify HCPCS code U0002 for all non-CDC labs reporting COVID-19 testing. Reimbursement levels are higher for non-CDC labs. You don’t want to just say “COVID-19 testing.” You want to be sure you are reimbursed at the proper level.
- Use CPT code 87635 for the detection of COVID-19 and any pan-coronavirus types or subtypes. Keep in mind that while “COVID-19” and “coronavirus” are often used interchangeably in the media, the first is a subset of the second. There are different coronaviruses, so if you are testing specifically for the strand tied to COVID-19 the coding must reflect that to maximize reimbursement under the various relief packages. Also be aware that next year there could be an entirely new strand, which again will have its own code. Specificity is your friend when seeking reimbursement.
- Monitor daily instances of these tests to prepare coding and billing for the volume of these new cases. You want to know which patients are coming into the hospital for testing, as well as who is coming back after being tested previously. Those who are returning will have different procedures and reimbursement schedules than those who are there for the first time. You also want to be sure that lab results are reliable and that you have a sufficient supply of tests to meet the demand.
- Review documentation prepared before CMS began accepting the new codes to ensure that it is coded accurately. Prior to April 1, 2020, local payers may have had different requirements for reporting. You now want to ensure that coding and documentation prepared early in the year are in line with current requirements.
- Draw the connection between patients who test for the virus and those who are admitted to the hospital. Those who test positive for COVID-19 will have more complications than those with simple flu or pneumonia, will likely have secondary and tertiary diagnoses and may require special equipment such as ventilators. All of that must be documented and coded accurately in order to receive full reimbursement. This is particularly important for patients who are admitted to the hospital first, then diagnosed with COVID-19 as their elevated risk could easily slip through the cracks when it comes to billing. At which point the hospital will be treating a complex COVID-19 patient without being reimbursed for all the services it is providing. It is critical to ensure the documentation lines up to the right level of diagnosis.
One other thing to keep in mind is that the situation with COVID-19 is constantly evolving. It’s a learning experience, with more information coming into play every day.
For example, there is now a possibility that the virus dates back to November or December 2019. If that is confirmed, patients who were diagnosed at that time with the flu or pneumonia may have had COVID-19 instead.
Hospitals will want to preserve the samples they took from that time in case they can retro-test and re-code those encounters later, enabling them to increase reimbursement to match the level of care delivered.
It can be difficult to think this way when the focus is on saving lives and keeping patients comfortable in the midst of terrible suffering. But the more that is done now to document and code COVID-19 accurately now, the better position hospitals will be in when the bill for all that care eventually becomes due.
Sean Kirby is SVP at VisiQuate, an advanced analytics technology and service company that helps some of the country's best-known healthcare providers and medical device makers achieve peak business health through yield improvement and cost optimization. Orlando Health uses VisiQuate's Revenue Management Analytics, Denials Management Analytics, Self Pay Analytics, and Charity Flo solutions to help them achieve peak business health so they can better fulfill their mission. Visit www.visiquate.com