The American healthcare system has been dealing with COVID-19 for a year now, and one thing we know for sure is that it is a dynamic situation.

Coding guidelines changed last April in response to the virus, and again in October. As of Jan. 1, there are dozens of new standards in place, and we expect more to come. The Paramount Health Solutions CDI/DRGV team is seeing a tendency to make errors related to compliance and population health as a result of all of the COVID-19 guideline changes. The number one error we’re seeing relates to testing and diagnosis of COVID-19. CMS requires documentation of COVID-positive patients, including whether the positive COVID test result was done in the 14 days prior to hospital admission. You can’t code a COVID diagnosis unless and until you have a positive test result. However, there are many times when a positive test result comes from different sources other than the hospital. From a coding perspective, we have to make sure that the population health metric is valid in terms of who gets tagged as having a confirmed COVID-19 case versus those who don’t. Per CMS, “a viral test performed within 14 days of the hospital admission, including a test performed by an entity other than the hospital, can be manually entered into the patient’s medical record to satisfy this documentation requirement.” The AMA sent a letter last fall to CMS saying “the new requirement will put substantial administrative burden on hospitals at a time when they are focusing their efforts and resources on critical patient care. We urge CMS to allow provider documentation to suffice if the test result is unavailable.”

According to the Association of Clinical Documentation Integrity Specialists, here are things that facilities need to consider regarding the positive COVID-19 diagnosis:

1. If the test result was taken in-house, then ensure that the results are linked to the patient’s record.
2. If the test was taken by an outside facility, health department or other entity, a mechanism to generate the request for the test result is needed as well as a process for follow up, as there may be a time delay in receiving the requested information.
3. Additional questions to consider:
   1. Will you extend the discharged, not final-billed, timeframe while awaiting the test results?
   2. Will you re-bill once the positive test result is received?
   3. What happens if the patient refuses to sign an authorization to release the test result from a different organization?
   4. Will the facility make the decision to retest the patient in-house?
   5. How will the facility handle false COVID results when the provider determines that the patient has COVID based on symptoms?
   6. Will the facility use the ambiguous CMS process in place for which they will give consideration for these scenarios without a stated turn-around time? Or will the facility retest the patient internally to avoid long waiting periods that may occur with CMS backlog for reconsideration due to this new requirement?

The PHS team helps clients navigate and respond appropriately to the many changes happening in the healthcare industry, from COVID-19 and other coding standards to catching errors and omissions and submitting clean, accurate claims, as well as ongoing physician and staff training.

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