NARRATOR: Welcome to Mayo Clinic COVID-19 Expert Insights and Strategies. The following activity is supported in part by an independent medical education grant from Pfizer Inc and is in accordance with ACCME guidelines.

PENNY JEFFERSON: Hi, my name is Penny Jefferson. I'm a clinical documentation specialist at Mayo Clinic in Arizona. I will be discussing coding and billing for the COVID-19 patient and what you need to know. I would like to give a special thank you to Annette Danks, Cindy Avery, Cindy Pritchett, Judy Dokken, and Savannah Zins for assistance with content review.

Mayo Clinic destination locations are Phoenix, Arizona, Rochester, Minnesota, and Jacksonville, Florida. At the end of this presentation, you will have an advanced understanding of and the ability to apply outlined coding guidelines to daily practice for accurate and complete billing as well as demonstrate proper use of documentation guidelines for confirmed and presented positive cases of COVID-19. You'll be able to identify opportunities to capture the correct principle diagnosis through the use of present on admission indicators and identify the impact of COVID-19 on billing and reimbursement for the hospital or providers and funds allocated for assistance by the CARES Act.

For confirmed and presented positive cases of COVID-19, use code U07.1. If COVID-19 is documented as suspected, probable, or inconclusive, do not use code U07.1. Instead, assign a code explaining the reason for the encounter, such as fever, or Z20.828, which is contact with and suspected exposure to other viral communicable diseases.

When COVID-19 meets the definition of principal diagnosis, use code U07.1. Principal diagnosis is defined as, "that condition established after study to be chiefly responsible for occasioning the inhibition of the patient to the hospital for care." Coding guidelines state COVID-19 should be sequenced first, followed by the appropriate codes for associated manifestations except in the case of sepsis due to COVID-19 present on admission, obstetrics patients, or patients admitted with transplant complications.

Respiratory illnesses due to COVID-19 are pneumonia, acute bronchitis, or respiratory infections and acute respiratory distress syndrome. The principal diagnosis would be U07.1 COVID-19 as the principal diagnosis followed by each of the specific manifestations associated with COVID-19. Pneumonia confirmed as due to COVID-19 would be coded as other viral pneumonia J12.89. For a patient with acute bronchitis confirmed as due to COVID-19, assign code J20.8, acute bronchitis due to other specified organisms. Bronchitis not otherwise specified due to COVID-19 should be coded using J40, which is bronchitis not specified as acute or chronic.

If COVID-19 is documented as being associated with a lower respiratory infection not otherwise specified or an acute respiratory infection not otherwise specified, use code J22, unspecified acute lower respiratory infection. If COVID-19 is documented as being associated with a respiratory infection not otherwise specified, code J98.8, other specified respiratory disorders. For Acute Respiratory Distress Syndrome, ARDS, due to COVID-19, assign code user U07.1 and J80, Acute Respiratory Distress Syndrome.

Coding a possible exposure to COVID-19 ruled out after evaluation, use code Z03.818, encounter for observation or suspected exposure to other biological agents ruled out. Coding of actual exposure to someone with COVID-19 confirmed or suspected, and the test results are negative or results are unknown, assign code Z20.828, 0.8 which is contact with and suspected exposure to other viral communicable diseases. For individuals who are being screened for COVID-19 with no known exposure to the virus, and the test results are either unknown or negative, use code Z11.59. Asymptomatic individuals who test positive for COVID-19, assign code U07.1. Although the individual is asymptomatic, the individual has tested positive and considered to have COVID-19.

For individuals presenting with signs or symptoms associated with COVID-19, such as fever, cough, or shortness of breath, and no definitive diagnosis has been established, use the appropriate code or codes for each of the presenting signs and symptoms, such as R05 for cough, R06.02 for shortness of breath. For fever unspecified, use code R50.9, et cetera. For individuals who have had actual or suspected contact or exposure presenting the signs and/or symptoms of COVID-19, assign code Z20.828 as an additional code. Women admitted with or presenting for a health care encounter during pregnancy, childbirth, or the puerperium, because of COVID-19, the principal diagnosis will be O98.5, other viral diseases complicating pregnancy, childbirth, or the puerperium. U07.1 will be listed as a secondary diagnosis followed by any appropriate codes for associated manifestations.

Cytokine Release Syndrome and Cytokine Storm Syndrome are used interchangeably in literature. Cytokine Release Storm is a systemic inflammatory response to infections and certain immunotherapies that trigger the immune system. The reaction to the cytokine release varies from mild symptoms to life threatening organ failure or even death.

Currently, further clinical data suggest evidence of mild or severe Cytokine Release Syndrome in severe COVID-19 patients. Consequently, treatment of the cytokine storm has become an important part of saving severe COVID-19 patients. There has also been a new coding clinic released in fourth quarter 2020 that addresses how to code the Cytokine Release Syndrome due to COVID-19.

Question and answer for coding Cytokine Release Syndrome due to COVID-19-- question, the patient was admitted for treatment of Cytokine Release Syndrome grade 3 due to COVID-19. What is the appropriate sequencing for this admission? Assign code U07.1 COVID-19 as the principal diagnosis. Assign code D89.833 Cytokine Release Syndrome grade 3 as an additional diagnosis.

This sequencing is supported by the instructional note that subcategory D89.83 Cytokine Release Syndrome to code first the underlying condition. This slide includes reference for coding scenarios of what codes to use and when appropriately. Note the sequencing of COVID-19 and sepsis is dependent on admission status.

In response to the COVID-19 pandemic, the Centers for Medicare and Medicaid Services implemented 12 new ICD-10-PCS procedure codes to describe the introduction or infusion of therapeutics for the treatment of COVID-19, effective with discharges on or after August 1, 2020. These codes should only be assigned when these drugs are administered to treat COVID-19. When a more specific ICD-10-PCS code exists, such as a stem cell transfusion, assign that code rather than one of less specific technology codes.

The new codes for introduction of other new technology-- therapeutic substances are only intended for new substances that are not classified elsewhere in ICD-10-PCS. This is a quick reference table for the added procedure codes to capture the introduction or infusion of therapeutics to treat COVID-19. As you can see, code XW033E5 is the procedure code for a patient that is receiving rem-desivir. Inclusion of these codes will aid in data collection for treatments provided to COVID-19 patients.

The coronavirus has taken a devastating toll on Americans across the country, whether in lives lost or economic impacts. The health care system is no different. Providers have been greatly affected as they strive to do the right thing, delaying elective surgeries, causing disruption in critical revenue streams.

Hospitals have been hit hard economically as well. Added equipment utilization for critically ill patients increased critical care staffing needs. These are massive amounts of PPE and cancellation of revenue-producing surgeries caused a sudden decline in revenue for hospitals and entire health systems. Non-essential employees were either furloughed or had hours cut to assist in revenue stabilization.

The CARES Act is a $2.2 trillion economic stimulus bill passed by President Donald Trump on March 27, 2020, in response to the economic fallout of the COVID-19 pandemic in the United States. The CARES Act has allocated $100 billion for health care providers. A portion of funding will be used to cover providers costs of delivering COVID-19 care for the uninsured. As a condition of receiving funds under this program, providers will be forbidden from balance billing the insured for the cost of their care. Providers will be reimbursed at Medicare rates.

The first round of the high impact relief fund to hospitals is a distribution of $10 billion. The primary driver for the costs related to COVID-19 is inpatient admissions to the hospital. The US Department of Health and Human Services identified those facilities with 100 or more COVID-19 admissions. These facilities encountered 129,911 admissions or over 70% of the total number of COVID-19 inpatient admissions reported.

The number of admissions encountered by these hospitals was then used to determine the allocation of relief funds across the pool of eligible recipients. Each recipient received funding equal to $76,975 per admission. Note, payments to these facilities on this basis is not intended to reimburse the facilities for their specific cost of these admissions. Rather, it came with COVID-19, admissions is being used as a proxy for the extent to which each facility experienced lost revenue and increased expenses associated with directly treating a substantial number of COVID-19 inpatient admissions. There are two more rounds of financial aid funds planned for hospitals.

The estimated financial impact is $50.7 billion per month, which is limited to the impacts analyzed. The total of four analyses completed over a four month period was $202.6 billion in losses for America's hospitals and health systems. The four analyses included the effects of COVID-19 hospitals and costs, the effects of canceled and foregone services caused by COVID-19 on hospital revenue, the additional costs associated with purchasing needed personal protective equipment or PPE, and the costs of additional support some hospitals were providing their workers.

Detailing of the reimbursements-- reimbursement will be based on current year Medicare fee schedule rates, except for otherwise noted. Publication of new codes and updates to existing codes will be made in accordance with published CNS guidance. For any new codes where a CMS published rate does not exist, claims will be held until CNS publishes corresponding reimbursement information.

When an individual no longer meets the need for acute inpatient care, the patient may remain in the hospital for public health reasons to prevent infecting other individuals. If the patient is a Medicare beneficiary and is a hospital inpatient for medical necessary care, Medicare will pay, for hospitals, the diagnosis related group rate and any cost outliers for the entire stay. This includes any of the quarantine time when the patient does not meet the need for acute inpatient care until the Medicare patient is discharged. It is extremely important for providers to document, in the medical record, the reason the patient remains in the hospital following inpatient acute care.

The Health Resources and Service Administration COVID-19 Uninsured Reimbursement program does not meet the definition of a health plan. The program is not subject to HIPAA requirements. The HRSA administrator states the program does not provide coding guidance for COVID-19. The program provides billing guidance to allow providers to identify and submit only claims eligible for reimbursement under this program, which is exclusively for reimbursing providers for COVID-19 testing of uninsured individuals and treatment for uninsured individuals when COVID-19 is the primary reason for treatment.

The American Health Information Management Association sent a letter to the administrator of the Health Resources and Services Administration expressing its concern that the HRSA's program guidance, directing providers to disregard official coding rules in order to receive reimbursement under the COVID-19 uninsured program, is a provider at risk of violations of the Health Insurance and Portability Accountability Act, or even charges of fraud and abuse by the Office of the Inspector General. AHIMA respectively disagrees with the HRSA's statement in its Frequently Asked Questions, that the ICD-10-CM Official Coding Guidelines do not apply to the HRSA uninsured COVID-19 program. Health care providers treating patients with COVID-19 diagnosis are HIPAA covered entities, and are therefore required to comply with the official coding rules and guidelines for HIPAA code set standards. Please click on the link for further resources.

Billing and reimbursement-- providers may submit claims for individuals in the US without health care coverage. Reimbursement will be based on current year Medicare fee schedule rates except where otherwise noted. Reimbursement will be based on incurred date of service.

Publication of new codes and updates to existing codes will be made in accordance with CMS. For any new codes where a CMS published rate does not exist, claims will be held until CMS publishes corresponding reimbursement information. Discharges of an individual diagnosed with COVID-19 will be identified by the presence of the International Classification of Diseases 10th Revision Clinical Modification Diagnosis Codes for COVID-19. Medicare claims processing systems will apply an adjustment factor to increase the Medicare severity diagnosis related group. The MS-DRG relative weight that would otherwise be applied will be increased by 20% when determining IPPS operating payments for discharge as described above.

The CARES Act 20% adjustment can only be applied when the actual lab test is in the medical record during the stay or dated within 14 days of admission. Positive tests must be demonstrated using only the results of viral testing, such as molecular or antigen consistent with the CDC guidelines. The test may be performed either during the hospital admission or prior to the hospital admission.

In the rare circumstances where a viral test was performed more than 14 days prior to the hospital admission, CMS will consider whether there are complex medical factors in addition to the test result for purposes of this documentation requirement. Coding and billing of COVID-19 will be an evolving process. For any questions related to current practice following the date of this presentation, please reference the current year guidelines. Please follow the link below for the 2021 official coding guidelines. Thank you.