August 31, 2020 / Jeff Lagasse, Associate Editor
While the effects of COVID-19 on the human body are still being studied, one thing that’s clear is that many patients who survive coronavirus-related hospitalizations still have a substantial need for post-acute care services. But a problem arose: Hospitals that continue to treat patients who no longer meet inpatient criteria are faced with denials up to $1 million in some cases.
According to the Department of Health and Human Services, sloppy coding results in more than $267 million in Medicare overpayments for post-acute care transfers to home healthcare services. Effective September 1, the Centers for Medicare and Medicaid Services requires that inpatient COVID-19 claims have a positive viral test result, challenging the requirements for increased MS-DRG weighting under the Coronavirus Aid, Relief, and Economic Security Act. 
According to Becky Greenfield, attorney with Wolfe Pincavage, CMS was concerned there would be some potentially fraudulent activity among hospitals in order to get the 20% bump in DRG payments – hence the new requirement of a molecular or antigen test. If no test is documented, Greenfield said Medicare would likely take the claim, but not pay the extra 20%.
Where this gets thorny is that hospitals are only permitted to use the code if the test shows a positive result, meaning it excludes those patients who are presumed positive or suspected to have contracted the coronavirus.