New Medical Record Compliance Challenges – Payment for COVID-19 and Patient Appeals to the QIO

Original story posted on: September 16, 2020

Hospital medical records are under scrutiny by the Centers for Medicare & Medicaid Services. 

Via two unrelated changes, the Centers for Medicare & Medicaid Services (CMS) is targeting the hospital medical record for added scrutiny.

It is clear that caring for patients during the COVID-19 pandemic costs more than during “normal times.” Even when caring for non-COVID patients, hospital staffers are using personal protective equipment. Every patient requires extra screening to ensure that they are not in the asymptomatic phase of infection. 

To help offset some of these costs, CMS has done several things. First, a new HCPCS code, C9803, was established for use by hospitals when the only service provided to a patient was collection of a COVID-19 swab. Second, they are allowing physician offices to report 99211 for that service, if performed in the office without another service. Lastly, and most significantly, a provision of the Coronavirus Aid, Relief, and Economic Security (CARES) Act provided a 20-percent increase in DRG weighting for all inpatient admissions for treatment of COVID-19. This simply required that the ICD-10 code for COVID-19 appear on the claim.

But, as CMS announced in an update to MLN Matters, SE20015, as of Sept. 1 there must also be a documented positive COVID-19 test result in order to qualify for this additional 20 percent. While this seems like common sense, we should remember that the current COVID-19 tests available can produce up to a 25-percent false negativity rate, meaning patients who clinically have COVID-19 (and are treated for COVID-19) may not have a positive test result to qualify for this addition. Furthermore, many patients get their COVID-19 testing done at outside facilities or at temporary testing locations. Obtaining that written test result can be daunting, if not impossible. There also continues to be a shortage of testing supplies, so it does not seem clinically appropriate to use one of those limited tests simply to get “proof” of infection when all clinical indicators support the diagnosis. CMS instructs hospitals to report “no pos test” on the claim to inform the Medicare Administrative Contractor (MAC) that the patient does not have a positive test documented in the medical record.

On the last CMS office hours call, the agency was asked if documentation by a provider that the patient had a positive test at an outside entity would suffice as proof of a positive test to qualify for the 20-percent increased payment. Although no answer was provided at that time, I have received confirmation from a CMS official that an actual copy of the positive test result is required, meaning documentation that the patient had a positive test will not suffice. Adding to the importance of this issue is that the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) has already added the 20-percent payment increase to its 2020 OIG Work Plan.

Unrelated to COVID-19, but in the 2021 Inpatient Prospective Payment System (IPPS) Final Rule, CMS addresses the usual myriad of topics, including establishing new DRGs for CAR-T therapy and hip fractures, and making the usual updates to payment rates to hospitals for inpatient care. But deep within the rule, CMS also chose to adopt a new requirement for how hospitals provide medical records to Quality Improvement Organizations (QIOs) for case reviews and audits. The QIOs perform several duties under contract to CMS, including reviewing high-weighted DRG claims for proper code assignment, auditing short inpatient stays for correct admission status, and reviewing complaints about violations of the Emergency Medical Treatment and Labor Act (EMTALA) statutes. When responding to these reviews, hospitals transmit the records to the QIOs by various means, printing out the medical record and mailing the paper copy, copying the record onto a CD or flash drive and mailing that to the QIO, printing out the record and faxing it, or transmitting the record via a secure electronic system, such as the CMS esMD system.

In 2020, it makes sense that the reliance on CDs and fax machines end and all medical records for audits be transmitted electronically, but it seems that this new requirement was adopted without considering one of the crucial duties of the QIO – reviewing immediate discharge appeals by patients. In these circumstances, the patient remains in the hospital and the record remains open. And while the new requirement is that providers must transmit the records to the QIO within 14 days, when a patient appeals their discharge, the QIO expects to receive the records within hours. Access to transmit records electronically is likely limited to staff in the health information management (HIM) department, and transmitting records for a patient’s discharge appeal on a weekend is unlikely to happen in a timely manner.

Before hospitals start training their case managers in using the esMD system, in a personal correspondence with CMS, I was informed that although hospitals are required to transmit electronically, there is no penalty for not doing so. In situations such as patient discharge appeals, the records can continue to be faxed, but the hospital will not be paid by the QIO for transmitting the records via fax, as the current regulations allow.

This does raise an interesting issue. If CMS says that hospitals will not be compensated for sending medical records via fax as of Oct. 1, does that not mean that hospitals should have been compensated for faxing records for discharge appeals prior to Oct. 1? I asked two case management leaders at two health systems, and both informed me that to their knowledge, their hospitals do not get paid for faxing records to the QIO for these appeals, although both said they cannot be certain that the QIOs are not automatically sending a payment to the hospital when records are faxed.

Although COVID-19 payments and patient discharge appeals seem to be totally unrelated, in both cases, ensuring the accuracy of and transmitting the contents of the medical record play a crucial role in meeting the changing requirements of CMS.

Programming Note: Ronald Hirsch, MD is a permanent panelist on Monitor Mondays. Listen to his live reporting every Monday at 10 EST.

Ronald Hirsch, MD

Ronald Hirsch, MD, FACP, CHCQM-PHYADV, CHRI, FABQAURP is vice president of the Regulations and Education Group at R1 Physician Advisory Services. Dr. Hirsch’s career in medicine includes many clinical leadership roles at healthcare organizations ranging from acute-care hospitals and home health agencies to long-term care facilities and group medical practices. In addition to serving as a medical director of case management and medical necessity reviewer throughout his career, Dr. Hirsch has delivered numerous peer lectures on case management best practices and is a published author on the topic. He is a member of the Advisory Board of the American College of Physician Advisors, a member of the American Case Management Association, and a Fellow of the American College of Physicians. Dr. Hirsch is a member of the RACmonitor editorial board and is regular panelist on Monitor Mondays.

The opinions expressed are those of the author and do not necessarily reflect the views, policies, or opinions of R1 RCM, Inc. or R1 Physician Advisory Services (R1 PAS).

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