According to the report, CMS should recover overpayments of $1 billion resulting from incorrectly assigning severe malnutrition diagnosis codes to inpatient hospital claims, ensure that hospitals bill appropriately moving forward, and conduct targeted reviews of claims at the highest severity level that are vulnerable to upcoding.
In a previous audit, the OIG found that hospitals incorrectly billed Medicare for severe malnutrition diagnosis codes for 173 of the 200 claims that we reviewed.
In that audit, the OIG found that hospitals used severe malnutrition diagnosis codes when they should have used codes for other forms of malnutrition or no malnutrition diagnosis code at all, resulting in net overpayments of $914,128 for the claims in its sample, the OIG said.
"On the basis of our sample results, we estimated that hospitals received overpayments of $1 billion for incorrect severe malnutrition diagnosis codes for fiscal years 2016 and 2017," the report said.
At the time, the OIG said it also found that hospitals are increasingly billing for inpatient stays at the highest severity level, which is the most expensive. The number of stays at the highest severity level increased almost 20 percent from fiscal year 2014 through fiscal year 2019, ultimately accounting for nearly half of all Medicare spending on inpatient hospital stays, the report said.
To remedy the situations the OIG gave CMS a lengthy list of suggestions, and while the OIG says CMS has started to take initial steps toward implementing the recommendations, there is more work to be done; thus, landing this issue on the 2022 list.
"In response to our recommendation that CMS conduct targeted reviews of Medicare Severity Diagnosis Related Groups and stays that are vulnerable to upcoding, as well as the hospitals that frequently bill them, CMS did not concur but acknowledged that there is more work to be done to determine conclusively which changes in billing are attributable to upcoding," the OIG said.
Further oversight and recovery audit contractor reviews, which are already being conducted, are essential to ensuring that Medicare dollars are spent appropriately, the report noted.
Strong CDI and physician collaboration directly contributes to the overall health of an organization's revenue cycle.
With the growth of automation, data availability, and tracking, it is increasingly important for the middle revenue cycle to become a priority for healthcare organizations, and department collaboration is the key to success.
That's why Kearstin Jorgenson, operations director of physician advisor services, and Dr. Kory Anderson, medical director of physician advisor services, CDI, and quality, at Intermountain Healthcare worked to streamline their middle revenue cycle by bringing their physician and CDI teams together.
Here are three tips they have for other revenue cycle leaders looking to improve team collaboration.
Center key performance indicators (KPI) on quality metrics
Dr. Anderson and Jorgenson have talked to numerous facilities around the country, and they see many aligning under a finance focus. Finance can be the loudest message sometimes, but what needs to resound is quality, they said.
Intermountain Healthcare focused on quality metrics that were directly impacted by clinical documentation, physician engagement, and education.
"We used to struggle to get an audience," Dr. Anderson said. "Now people are coming to us to talk about strategies and what they could do to improve those metrics."
Bring teams together in a way that still enables them to do their best work
For Intermountain Healthcare, the CDI nurses continue to focus on trends and identify what the team needs to learn. They collaborate with the physicians, and then the physicians go out and build relationships, look for common and shared understanding, and deliver educational presentations.
Bring education work in-house when possible
Intermountain Healthcare used to contract education out to vendors. Now the team does in-house training whenever possible.
Dr. Anderson and Jorgenson say they're getting better engagement with providers because educational sessions are happening between colleagues.
The person leading the session and those who attend see and work with each other in the hospital every day. This allows for more natural accountability and continuous improvements and adjustments because conversations can happen on the job and in the moment, they said.
Follow-through is also greater with in-house education. Intermountain Healthcare has set up quarterly meetings to connect on what’s going well, what isn’t going well, and how to close the gaps.
Reported housing instability is linked to higher hospital admission rates for mental disorders, longer inpatient stays, and substantial healthcare costs, a recent study found.
Social determinants of health (SDOH) are social factors, such as homelessness, illiteracy, a history of childhood trauma, and joblessness or underemployment, that can affect a person’s health.
With increasing attention on population health and quality initiatives, organizations have turned their focus on SDOH and how capturing those ICD-10-CM codes impacts their patient population and their success in caring for that population.
As your middle revenue cycle works to report SDOH more accurately, a recent study is now showing what can be learned from reporting these diagnosis codes appropriately.
A recent study published in JAMA Network Open found that reported housing instability is linked to higher hospital admission rates for mental disorders, longer inpatient stays, and substantial healthcare costs.
Researchers at the University of Michigan Institute for Healthcare Policy and Innovation reviewed more than 87 million hospital records for patients 18 to 99 years old using the 2017 to 2019 national inpatient sample. The researchers then screened those records for the ICD-10-CM codes related to housing instability.
The researchers then analyzed the records to determine associations between coded housing instability and reason for inpatient hospitalization, length of stay, and cost of admission.
Researchers found that housing instability was associated with higher rates of admission for mental, behavioral, and neurodevelopmental disorders. In addition, housing instability was significantly associated with longer hospital stays (6.7 versus 4.8 days) and high medical costs.
Between 2017 and 2019, inpatient hospitalization costs for patients with coded housing instability was $9.3 billion. These findings highlight the importance of improving tracking of housing status in healthcare and taking steps to better address the needs of patients experiencing homelessness.
Lifepoint Health's vice president of revenue cycle operations chats about trends the health system is watching for 2023.
Hospitals and health systems have been struggling financially as they try to navigate rising expenses.
Challenges like this mean organizations are going to finish out the year in the red, according to recent reports from Kaufman Hall.
As organizations plan to tighten their belts in 2023, revenue cycle leaders are feeling the pressure of cost cutting, regulatory burdens, and staffing shortages.
HealthLeaders recently chatted with Tina Barsallo, vice president of revenue cycle operations at Lifepoint Health, to get a better idea of the revenue cycle trends the health system is following for 2023 and how it navigated challenges in 2022.
HealthLeaders: How has the financial strain on hospitals affected your revenue cycle in 2022? Did budget cuts or restraints have you adjusting any workflows or processes?
Tina Barsallo: Reductions and the strains on ability to hire have created the need for additional automation around patient access and patient self-scheduling here at Lifepoint.
Also, manual claim reviews and delays in authorizations with payers have caused increased denials, appeal delays, and untimely payment. As payers allow, additional Joint Operations Committee meetings have been established to work through delays and various processing backlogs.
Staffing challenges have also created the need for modified workflows on low balance insurance follow up and need to outsource/offshore certain customer service and follow up activities.
HealthLeaders: What was your biggest obstacle in the revenue cycle for 2022 and how did you overcome it?
Barsallo: Staffing and recruitment. Changes in payer policies and behaviors post-pandemic drove the need to establish new approaches, modify workflows, and additional payer meetings without additional resources at best.
Pictured: Tina Barsallo, vice president of revenue cycle operations at Lifepoint Health. Photo courtesy of LinkedIn.
HealthLeaders: What trends do you see coming for revenue cycle leaders in 2023?
Barsallo: In 2023, we anticipate we will continue to see the same challenges, such as staffing challenges, regulatory changes (like pricing transparency and the No Surprises Act), payer policy changes with limited notice, higher volume of post-pay reviews, and denials and underpayments as a result.
On a positive note, CMS has delayed enforcement of part of the No Surprises Act which will give us the much-needed time to work on ways to automate the good faith estimates, an essential part of the act.
HealthLeaders: On that note, what regulatory burdens are you watching the closest for 2023?
Barsallo: Definitely the No Surprises Act. We want to create ways to better automate and communicate the good faith estimates with co-providers, patients, and payers.
HealthLeaders: What is one goal you have for your revenue cycle in 2023?
Barsallo: In 2023 we want to implement patient experience technology to help minimize resource constraints and improve performance (reduced wait times, speed to schedule, etc.) by increasing automation and patient self service capabilities. We also want to offer scheduling ‘as a service’ at our facilities.
Enforcement for certain good faith estimate (GFE) provisions are being delayed.
CMS recently gave revenue cycle leaders an extension of its enforcement discretion on the convening provider requirements that are part of the GFE in its newest FAQ.
Under the law, healthcare organizations need to give patients who don't have certain types of healthcare coverage—or those who are paying out of pocket—an estimate of their bill before services are provided.
Not only do these GFEs need to be created, but they also need to be created quickly as patients have the right to receive a GFE for the total expected cost of items and services as soon as they schedule an appointment (the items can include costs of tests, drugs, equipment, hospital fees, and more).
The GFEs also need to be accurate since patients can dispute final medical bills if the charges are at least $400 more than what was presented on the GFE.
On top of all of this, the rule also includes a "convening provider" requirement.
This means GFEs need to cover not only the provider’s own services, but those of downstream providers expected to be needed to complete treatment.
This specific requirement has been an area of contention for hospitals and medical groups. In fact, the MGMA recently pleaded with CMS to extend the enforcement discretion for the convening provider/facility and co-provider/facility provisions for GFEs.
At the time the MGMA said enforcement discretion should continue until appropriate standards have been developed, tested, and implemented by group practices.
According to the recently published new guidance, CMS said HHS is extending enforcement discretion, pending future rulemaking, for situations where GFEs for uninsured or self-pay individuals do not include expected charges from coproviders or co-facilities until further notice.
Enforcement of this part of the No Surprises Act requirement was expected to start January 1, 2023.
WEDI recently applauded this guidance and Charles Stellar, WEDI president and CEO, went on to say that "the industry continues to make progress in developing data interchange standards to support the requirements of the No Surprises Act. We commend HHS for extending the enforcement discretion period and averting significant administrative burdens on providers. The HHS action today grants the time necessary to develop cost efficient solutions and implement supporting regulations."
HealthLeaders' regulatory round up series highlights five essential governing updates that cover every aspect of the revenue cycle that leaders need to know. Check back in each month for more updates.
The revenue cycle is complex, detailed, and always changing, so staying on top of regulatory updates and latest best practices requires revenue cycle leaders' constant attention in this ever-changing industry.
In this revenue cycle regulatory roundup, there were an ample number of updates published by CMS and the OIG in November, including the OPPS and physician fee schedule final rules.
Here are the five updates you need to know.
Medicare providers did not always comply with federal requirements when billing for advance care planning.
The OIG published a review regarding whether Medicare providers who received payments for advance care planning (ACP) services in an office setting complied with federal requirements.
The OIG found that 466 of the 691 ACP services did not comply with federal requirements. Issues included providers claiming that they did not know that the time for ACP services had to be distinguished between time spent discussing ACP and time spent on concurrent services. Some providers said they were unaware there was a time requirement.
The OIG said that, based on this sample, it estimates that Medicare providers received approximately $42.3 million in payments for ACP services that did not comply with federal requirements.
The OIG also noted that it found some claims where 15 or more ACP services were received during the 12-month audit period, and while that did not reflect noncompliance, it did not align with CMS guidance in an FAQ suggesting that ACP services billed multiple times for a beneficiary should include a documented change in the beneficiary’s health status, end-of-life care wishes, or both.
The OIG recommends CMS educate providers on documentation and time requirements for ACP services, instruct the MACs to recoup the money paid in error for claims in the sample, and instruct the MACs to notify providers so they can identify, report, and return similar overpayments.
The OIG also recommends CMS establish requirements that address when it is appropriate to provide multiple ACP services for a single beneficiary and how these services should be documented to support the need for multiple ACP services. CMS concurred with all but the fourth recommendation.
Medicare improperly paid physicians for co-surgery and assistant-at-surgery services that were billed without the appropriate payment modifiers.
The OIG published another noteworthy review in November, this one focused on whether Part B payments to physicians for potential co-surgery procedures complied with federal requirements.
The OIG found that 69 of the 100 statistically sampled services did not comply with requirements. This included 49 services incorrectly billed without the co-surgery modifier, 14 incorrectly billed without an assistant-at-surgery modifier, and six that were incorrectly billed as duplicate services.
The OIG also reviewed 127 corresponding services and found that 62 of those did not comply with federal requirements, as 33 were incorrectly billed without the co-surgery modifier, 16 were incorrectly billed without an assistant-at-surgery modifier, and 13 were incorrectly billed as duplicate services. The OIG determined that these errors resulted in $56,016 in overpayments.
The OIG recommends CMS recover the portion of the $56,016 in Part B overpayments within the claim reopening period, instruct Medicare providers to identify, return, and report any similar overpayments, strengthen its system control to detect and prevent improper payments for these types of services, and update Medicare requirements and corresponding educational material to improve providers’ understanding of the Part B billing requirements for co-surgery procedures.
CMS concurred with these recommendations.
Medicare began its enrollment of rural emergency hospitals.
CMS published a transmittal regarding the addition of information about rural emergency hospitals (REH) enrollment applications to the manual.
This information walks through the process for a critical-access hospital or rural hospital wishing to convert to an REH and provides instructions for the contractors on processing these enrollment applications. The transmittal was originally published internally on September 15, but it is no longer sensitive information and is now posted for the public.
The 2023 Medicare physician fee schedule final rule was released.
CMS published the 2023 Medicare physician fee schedule final rule. The rule finalized a decrease in the conversion factor down from $34.61 in 2022 to $33.06 in 2023 (two cents less than the $33.08 listed in the proposed rule). Other policies finalized in the rule include:
Adopting coding/documentation changes for E/M visits (including hospital inpatient, observation, emergency department, and more) that align with changes made by the AMA CPT Editorial Panel for January 1, 2023. This includes eliminated use of history and exam to determine code level, revised interpretive guidelines for levels of medical decision-making, and the choice of medical decision-making or time in determining code level.
Delaying the split-shared visits policy until 2024. This policy will change the definition of the substantive portion as more than half the total time.
Extending the time that telehealth services are temporarily included on the telehealth services list during the PHE but are not included on a Category I, II, or III basis for 151 days following the end of the PHE. Providers should continue to report telehealth services with modifier 95 during the PHE, but audio-only services should be reported with modifier 93 effective January 1, 2023.
Making an exception to direct supervision requirements under “incident to” regulations allowing behavioral health services provided under general supervision of a physician or non-physician practitioner (NPP) when the services or supplies are provided by auxiliary personnel incident to the services of a physician or NPP.
Codifying the reporting of modifier -JW for reporting wastage for all separately payable drugs with wastage from single use vials or single use packages effective January 1, 2023, and the reporting of modifier -JZ for reporting single use vials or packages with no discarded amount effective July 1, 2023, with editing beginning October 1, 2023. Other issues were clarified in commentary.
Codifying changes to coverage of certain dental care inextricably linked to and substantially related and integral to the clinical success of covered medical services.
The rule is effective January 1, 2023.
The outpatient prospective payment system (OPPS) final rule was also released.
CMS published the 2023 OPPS final rule. The rule finalizes updates to both OPPS and ambulatory surgical center (ASC) PPS payment rates by 3.8% for 2023, significantly higher than the proposed 2.7% increase in payment rates.
Policies finalized in the rule include:
340B payment rate updates.
Removing 11 services from the inpatient-only list, adding eight services to the inpatient-only list, and adding four services to the ASC covered procedures list.
Continuing coverage for behavioral health services furnished remotely by hospital staff to beneficiaries in their homes beyond the end of the public health emergency (PHE) as long as the beneficiary receives an in-person service within six months prior to the first remote service and once every 12 months following that.
Adding facet joint injections and nerve destruction as an additional service that would require prior authorization, effective July 1, 2023, rather than the proposed date of March.
Approving four of the eight applications for device pass-through payments for CY 2023.
Finalizing changes to the supervision requirements for diagnostic services to allow non-physician practitioners to supervise diagnostic services within their scope of practice, similar to services provided under the physician fee schedule.
CMS is implementing a requirement from the Consolidated Appropriations Act of 2021 to establish REH as a new provider type. Critical access hospitals and certain rural hospitals may choose to convert to an REH and would be allowed to provide emergency department services, observation care, and certain outpatient medical and health services.
Discontinuing its reconciliation process was an easy decision for one revenue cycle leader at UC Davis Health.
2022 has been a financial struggle for most hospitals, and revenue cycle leaders have been tasked with helping to improve the bottom line. It’s no secret that one of the areas most closely tied to reimbursement is the middle revenue cycle.
When it comes to streamlining the middle revenue cycle to increase productivity and help that bottom line, one area leaders look to is the reconciliation process.
While some leaders believe the CDI and coding reconciliation process is an important step in proper documentation and denials management, other leaders have said the time spent reviewing the mismatches is not only bad for productivity, but team moral as well.
Tami McMasters Gomez, the director of coding and CDI services for UC Davis Health, made the decision to do away with its reconciliation process, and since she was armed with data, gathering support from other leaders was easy as well.
HealthLeaders: Did you find it easy to get other revenue cycle leaders on board with your decision to change this process up?
Tammy McMasters Gomez: I did. Once I was able to demonstrate the high accuracy rates of our coding team and show that I believed this process could be done more efficiently, there was a lot of buy in from our C-suite. By changing the way we did it, we had a lot of benefits.
HL: I know that we chatted about the 33% increase in productivity, but what other positive outcomes have you seen since changing this process?
McMasters Gomez: I will say that it allows individuals who are seeking education or feedback on their performance a chance at a daily interaction with a team member who is very direct and has an education background.
Previously, when we left it up to the coder and the CDI specialist to go back and forth and provide education to each other on why there was a DRG mismatch, it wasn’t very helpful because coders and CDI specialists don't necessarily speak the same language.
I think this new process has provided that direct feedback that’s easily digestible and referenced by material that is specific to that person. I think it's created a better understanding from the team because some of the feedback I got was: “I don't understand what the coders are saying,” or the coder would say “we don't code based off a clinical findings, we code based on documentation.” There was a lot of that back and forth.
Now all of that is done in a nice write-up format and presented back to the team, and in my opinion, it’s irrefutable because there's evidence, documentation, and all of the coding or CDI resources are presented back to the teams. It's created a great educational opportunity. And again, the CDI teams can now spend more time doing clinical reviews.
Also, that productivity piece has allowed us to spend more time looking at some of the more complex things. This change didn’t just increase team productivity, but it increased the integrity of the reviews and the type of reviews that we're doing. As the landscape is kind of moving more towards quality outcomes, we're able to better measure that performance.
HL: When taking on such a large endeavor like reworking an entire reconciliation process, revenue cycle leaders can be very hesitant. Can you give them any advice on moving forward and taking those first steps towards something like this? What can they say to their CDI or coding directors to get them on board?
McMasters Gomez: I think I would start by really looking at the time being spent on reconciliation and the impact it has on the teams.
And make sure you have a strong coding team first—it really does start with high coding accuracy rates. If you have a coding team that's not strong, the process you have in place may work.
That's how I think it evolved for us—we already had such a high accuracy rate, it didn't really make sense to have a reconciliation process in place where the CDI specialists were questioning the coders, because 99% of the time the coders were right already.
That’s why for us it was about making sure that we were more efficient in how this process was conducted. It's about efficiency.
I would tell revenue cycle leaders to demonstrate how the process is currently working when looking for buy-in on a change like this. Is it efficient? What's the time being spent on it? And then ask about those coding accuracy rates. If you have a very high coding accuracy rate and your coders are accurate 99.9% of the time during that DRG mismatch review, does it make sense to continue this reconciliation process?
The Director of Coding and CDI Services for UC Davis Health chats with Healthleaders about its leap of faith in discontinuing its reconciliation process.
At the heart of the revenue cycle are the CDI and coding teams, which is why revenue cycle leaders tend to focus here first when looking to rework processes, improve productivity, and increase the bottom line.
When it comes to streamlining the middle revenue cycle, one area leaders look to is the CDI reconciliation process.
Traditionally, a CDI and coding reconciliation process consists of a CDI specialist reviewing a chart, assigning a working diagnosis-related group (DRG), and occasionally determining a set of diagnosis and procedure codes proactively to help create queries, quality reviews, and more—all before the patient has even left the building.
Once that patient gets discharged, the coding teams report the case based on the documentation in the medical record. And, if the MS-DRGs and/or codes don't match what the CDI team chose, the chart could be passed back to the CDI team to identify the mismatch.
While some leaders believe this reconciliation process is an important step in proper documentation and denials management, other leaders have said the time spent reviewing the mismatches is not only bad for productivity, but team moral as well.
To discuss this further, HealthLeaders caught up with Tami McMasters Gomez, the director of coding and CDI services for UC Davis Health, about how she recently did away with her entire CDI and coding reconciliation process and found positive results from doing so.
This is part one of a two-part series.
HealthLeaders: We spoke earlier this year about the technology that UC Davis has been implementing in the middle revenue cycle. And at the time you mentioned to me about your organization's discontinued CDI reconciliation process. Since it seems to be the opposite of what a lot of revenue cycle leaders look to do, I was so eager to chat with you about it.
Revenue cycle leaders obviously know every aspect of the revenue cycle, but depending on an organization’s size, they may not be as in the weeds with CDI and coding as their directors are. So, we are chatting about this topic today because this change that you made in your department increased productivity by 33% and that can have a huge impact on the revenue cycle.
To start us off, can you give revenue cycle leaders a brief overview of what your CDI and coding reconciliation process looked like?
McMasters Gomez: Before discontinuation, if the teams’ DRGs didn’t match, there was a process where the coder would pass it back to the CDI specialist in a work-cue-type environment and say, “my DRG doesn't match yours, let's figure out why.” The CDI team would then spend sometimes 30 or 40 minutes trying to figure out why their DRG didn't match the coders.
In most cases, the CDI team does not consist of seasoned coders: they're clinical reviewers. And the mismatch could have been from an obscure coding guideline or a seventh character in a procedure code that the CDI specialist just wasn't aware of. It just didn't feel like it was very productive to have this process in place.
This process also created a low team moral. There was this back and forth between the teams and they were questioning me and asking, “why are we doing this?” It really felt like there could be a better way at UC Davis.
That's kind of what set this in motion for me. I needed to figure out how we could make the process more efficient and why this process was creating more problems in the unit and less team engagement.
Tami McMasters Gomez, director of coding and CDI services for UC Davis Health. Photo courtesy of HealthLeaders.
HL: What happened to make you see that discontinuing this entire process was the right move? And what was your process in implementing this change?
McMasters Gomez: As I mentioned, my wheels started turning about why this process was so adversarial and why the teams were going back and forth. I also began wondering why I was holding the CDI team to a coding standard when they're not coders.
We actually had two external audits done back-to-back in 2019 and 2020 to gauge our coding accuracy rates. I already knew we had a strong coding team, but the third-party auditors determined that we have a 99.9% coding accuracy rate.
I knew there was one benefit to having this reconciliation process, and that was the education the teams received from investigating or learning about why their DRGs didn't match when we have such high coding accuracy rates. And then I thought, well, “What can I do to take this process outside of these teams so that they could spend time doing what they do, coding and clinical reviews?”
That’s when I created a back-end process where I have clinical reviewers that get a daily report that shows all of the DRG mismatches. That review, which is done by both a high-level coding analyst/auditor with CDI credentials and a CDI lead, do the reviews and provide individual feedback to either the coder or the CDI specialist on why there was a difference in the DRG.
That review is done retrospectively prebill, and the individual feedback is provided to the team in real time prior to completing the case with the supporting documentation on why there was a DRG mismatch.
We also look for trends. If everybody's missing the boat on this one area, then we provide a much broader education or scope. But we really did a lot of looking at data and leveraging reports. And when there are coding errors or missed opportunities discovered, there's direct feedback daily to the coders so they're still getting that education.
We found that after implementing this change, CDI productivity increased more than it did the coders by anywhere between 25% to 33%. This new process really lets the coders be coders and the CDI specialists have more time to perform those clinical reviews and touch more cases.
And another added benefit was team morale. It really did just completely change the morale regarding the interaction between the coders and the CDI.
Revenue cycle leaders at these prominent organizations chatted with HealthLeaders about how they delt with the No Surprises Act implementation this year.
It has been a while since a regulation has shaken the revenue cycle as much as the No Surprises Act has.
As CMS continues to make changes to the various aspects of the No Surprises Act, the struggle to implement changes and adjust processes is far from over.
One of our top stories from 2022 detailed how organizations worked to implement and keep up with changes surrounding the No Surprises Act. As regulations continue to evolve into 2023, their stories are as pertinent as ever.
Karen Kennedy, director, revenue cycle, Cleveland Clinic, Ohio and Florida:
"Our planning and preparation for the No Surprises Act (NSA) was led by a cross-functional team including high-functioning caregivers from IT, legal, patient access, billing, self-pay follow-up, and education.
Members of this team meet weekly to create an overall strategy and manageable ongoing process that met all of the additional requirements of the NSA.
Although implementation was complex and resource intensive, Cleveland Clinic fully supports the legislation to protect patients from surprise billing."
Sarah Ginnetti, associate vice president of revenue cycle at UConn Health, Connecticut:
"As a result of preparing for that regulation, we did stand up another cross-functional team in the organization. We found a way to develop some workflows within Epic [and] identify the right team members to assign to some of this work in order to manage and respond to the No Surprises Act.
I think we actually have a pretty good process in place. It is very manual and that's the one thing I don't like about it. But we right now don't have the infrastructure set up around it to make it a more automated process. However, that is part of our roadmap going forward that's tied to the patient experience. [That will include] building out our estimate platform.
For all intents and purposes, we are, I would say, 90-plus percent compliant, and were as of January 1."
2022 brought many challenges for revenue cycle leaders, and COVID-19 reporting was no exception.
This past year was trying for hospitals for many reasons. From staffing shortages to financial challenges, revenue cycle leaders faced many trials in 2022.
One thing that is still top of mind for leaders though, is COVID-19 reporting. While COVID-19 might seem like old news at this point, its reporting and subsequent reimbursement is still of utmost importance. Because coding occurs mid-cycle, it provides an opportunity to catch errors introduced earlier in the process, as well as preventing similar errors in the future.
Staying abreast of these regulatory coding updates is important for revenue cycle leaders as coding—and its completeness and accuracy—has a profound impact on an organization's bottom line.
Its importance was proven as our article on COVID-19 reporting hit one of the top spots for 2022. Here’s what you—and your middle revenue cycle—still need to know about reporting COVID-19 ICD-10-CM diagnosis codes.
Thanks to various code updates since the beginning of the pandemic, there is now a long list of COVID-19 diagnosis codes.
Here are the ICD-10-CM codes that specifically represent COVID-19:
J12.82, pneumonia due to coronavirus disease 2019
U07.1, COVID-19
U09.9, post COVID-19 condition, unspecified
Z11.52, encounter for screening for COVID-19
Z20.822, contact with and (suspected) exposure to COVID-19
Z28.310, unvaccinated for COVID-19
Z28.311, partially vaccinated for COVID-19
Z86.16, personal history of COVID-19
Make sure your teams keep in mind that specific documentation isn’t necessarily needed for COVID-19 code assignment.
The 2022 ICD-10-CM Official Guidelines for Coding and Reporting state that physicians do not have to specifically document “COVID-19” for code U07.1 (COVID-19) to be assigned.
Per ICD-10-CM guidelines, code only a confirmed diagnosis of COVID-19 as documented by the provider, or documentation of a positive COVID-19 test result.
This guideline allows U07.1 to be assigned if the documentation includes a positive COVID-19 laboratory result.
Coding Clinic, Second Quarter 2020, provided additional clarification on this, too. It said that the provider does not need to explicitly link the test result to the respiratory condition, the positive test results can be coded as confirmed COVID-19 cases as long as the test result itself is part of the medical record.
“As stated in the coding guidelines for COVID-19 infections that went into effect on April 1, code U07.1 may be assigned based on results of a positive test as well as when COVID-19 is documented by the provider. Please note that this advice is limited to cases related to COVID-19 and not the coding of other laboratory tests,” it said.
Never assume that COVID-19 was present on admission.
If a physician doesn’t specifically state a patient acquired the COVID-19 infection in your hospital, it is still not appropriate for your teams to assume it was present on admission. In fact, per the ICD-10-CM guidelines, a provider should be queried regarding issues related to the linking of signs/symptoms, timing of test results, and the timing of the findings.
There are COVID-19 vaccine codes for all hospital types: both inpatient and outpatient.
ICD-10-CM diagnosis codes for vaccine status are for all patient types. The vaccine CPT® codes are for outpatient reporting. There are also ICD-10-PCS codes for inpatient reporting of COVID-19 vaccines.
