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CMS to Require Positive Test for COVID-19 Add-on Payment

In an Aug. 17 Medicare Learning Network (MLN) Matters article, the Centers for Medicare & Medicaid Services (CMS) updated rules governing the Medicare add-on payment for inpatient prospective payment system hospitals’ treatment of individuals diagnosed with COVID-19.

Section 3710 of the Coronavirus Aid, Relief, and Economic Security (CARES) Act, directs HHS to increase the weighting factor of the assigned diagnosis-related group by 20 percent for an individual diagnosed with COVID-19 discharged during the public health emergency period.

CMS clarifies that for admissions on or after Sept. 1, claims eligible for the 20 percent increase in Medicare payments will be required to have a positive COVID-19 laboratory test documented in the patient’s medical record. Positive tests must be demonstrated using only the results of viral testing (i.e., molecular or antigen), consistent with CDC guidelines. The test may be performed either during or prior to the hospital admission.

The agency notes that 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.

Further, a hospital that diagnoses a patient with COVID-19 but does not have evidence of a positive test result can decline, at the time of claim submission, the additional payment to avoid repayment.

We encourage all members to visit the America’s Essential Hospitals coronavirus resource page for more information about the outbreak.

Contact Senior Director of Policy Erin O’Malley at eomalley@essentialhospitals.org or 202.585.0127 with questions.

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About the Author

Abigail Painchaud is a policy associate at America's Essential Hospitals.

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