The Quest for Clean COVID Claims
By Selena Chavis
For The Record
Vol. 33 No. 3 P. 14
Experts weigh in on lessons learned over the past year and new best practices for the revenue cycle.
No doubt, the challenges that COVID-19 has introduced to the health care industry are unprecedented. From patient throughput to supply chain, nearly every aspect of the industry has faced an uphill battle. Revenue cycle has certainly not been immune to these trends. As the dust settles on the pandemic, lessons learned during the time and best practices developed because of it will undoubtedly continue to surface for years to come.
On the financial front, the past year has left provider organizations operating within razor-thin margins. One report released in September 2020 suggests that for-profit hospitals will continue to see a financial decline for another 12 to 18 months. In tandem with those challenges, health care organizations face mounting compliance concerns related to not only new COVID-19 guidance and telehealth but also the introduction of new evaluation and management codes. Consequently, revenue integrity practices that prioritize denials management will be paramount to sustainability going forward.
Interestingly, industry professionals suggest that while there have been some direct challenges related to COVID-19 claims and denials, the greater challenges over the last year may not be what the average HIM professional would have expected.
“There are, of course, some trends related to COVID-19,” says Karen Youmans, MPA, RHIA, CCS, founder and CEO with YES HIM Consulting. “But every health care facility is looking more closely at denials management due to various reasons, including COVID-19 coding and billing, varied payer clinical criteria for sepsis, new or revised clinical criteria for severe protein-calorie malnutrition, managed care contract language, etc.”
Lori Brocato, vice president of product management with The SSI Group, points out that the highest trending denials continue to be related to eligibility and coordination of benefits. “You could tie this into COVID because a lot of people lost their jobs and probably lost insurance. So, you know that providers have that insurance on file still and are probably filing claims with it. That could be one reason we continue to see those denials stay on top,” she says.
Denials in the form of patient responsibility are top of mind, notes Matt Seefeld, executive vice president of MedEvolve. “That theme is somewhat COVID related, but where it’s not COVID related is in the mainstreaming of high-deductible plans. Out of pocket for the patient is going to be much higher today than it was five years ago, and certainly 20 years ago,” he explains, adding that patient-responsible balances are expected to be a greater issue in 2021 as deductible season extends into midyear. He suggests that a lot of people who would normally have surgeries completed early in the year are postponing as they wait to be vaccinated, slowing down the pace at which insurance kicks in.
Amid multiple and growing revenue cycle challenges, health care organizations will certainly want to make sure that their COVID claims are buttoned up. Experts share what the industry has learned thus far and how to prepare for future success.
COVID Claims: What We’ve Learned
In terms of the evolution of COVID-19 documentation and billing, Tracey Goessel, MD, CEO and cofounder of FairCode Associates, says there is a wide variance in how the principal diagnosis has been identified across the industry. Additionally, the industry has faced ongoing challenges with changing guidance.
“When COVID first came, the government rule was that patients did not need to have a positive COVID test. If the doctor said it was COVID, it was COVID,” Goessel says, pointing out that this ruling was based on an unacceptably high false-negative rate. “Then come September, the rules changed to, ‘You have to have a positive PCR [polymerase chain reaction].’ Has everybody kept up with that rule? Who knows? They're just trying not to drown in a sea of calamity.”
The addition of six new codes exacerbated the situation. Goessel points to 21 new procedures codes as of January 1, 2021, and 10 new codes for monoclonal antibodies and other drug classes. “So you've got all kinds of administrative rule changes. At the same time, there is an evolving set of treatments that people are trying to figure out as we go along,” she says. “There is a steep learning curve to all this, and right now, the hospitals themselves are suffering from staffing issues as people are getting sick and dying. It’s really the perfect storm of impossibility.”
Brocato says there have been a few blips along the way related to the ongoing changes. Notably, some problems were associated with payer readiness with the new COVID-related codes. “Claims would kick back for invalid codes, or what a lot of payers did was just hold the claims until they knew they were going to have the codes in their system and process them then,” Brocato says.
In particular, Brocato notes that the industry is seeing a lot of rejections from the Health Resources and Services Administration’s uninsured program. “There are a lot with that one payer because it's specific to COVID, so anything that gets denied is going to be COVID related,” she explains, adding that overall, the industry has not seen COVID claim errors to the degree that many were anticipating. “I think a reason why we didn't see a lot of claim errors is because of the systems people had in place. We're very proactive about getting edits put in place and being prepared with the data. I think that the industry in general did a pretty good job with that considering the short timeframes.”
In terms of the foundation of a clean COVID claim, Goessel points to a positive PCR and the ability to get a doctor to document the link between COVID and accompanying conditions such as pneumonia or sepsis.
Youmans identifies two problematic areas: Monoclonal antibody infusions are paid only for outpatient encounters and the Z23 (encounter for immunization) code needs to be the first diagnosis code listed. “This oddity in coding is due to the CARES Act publishing approval for both the vaccine and the monoclonal antibody infusions at the same time,” she explains.
As a best practice, Youmans suggests keeping an eye daily on the Centers for Medicare & Medicaid Services (CMS) website and exploring the frequently asked questions section on the CMS, AHIMA, and American Hospital Association websites. She also recommends keeping tabs on the appropriate Medicare Recovery Audit Contractor’s website to stay on top of the correct coding and billing guidelines and instructions.
In addition, there should be consistent communication between physicians and the HIM coding, compliance, and billing departments.
Prioritizing Denials Management: An Industry Imperative
Brocato believes the pandemic has had a wide-ranging effect on denials management. While health care organizations, by and large, recognize the need to prioritize this area of the revenue cycle process, the events of 2020 certainly threw them a curve ball.
In some ways, the decrease in nonemergency visits provided time for digging into areas of denials that many organizations may have been neglecting. In other cases, staffing issues may have required reallocation of back-end staff—who would have normally engaged in denials management—to front-end processes.
Seefeld suggests that the pandemic has reinforced the need to focus more on denials management—an area of revenue cycle that needed attention prior to the pandemic. “When you're writing off three, four, or five cents on the dollar or more a year, that's a major problem pre-COVID; it’s not even possible to maintain a business post-COVID,” he says. “There are too many changes now—the visit volumes, the procedure types, and payer mixes—all those things are happening that have nothing to do with your ability to be efficient with revenue cycle.”
Especially during a pandemic, health care organizations lack the ability to dictate the types of procedures and payers they are taking in. Seefeld points out that subtle changes in services and payer mix can either give providers an uptick in cash flow or a significant reduction. “A lot of our AI analytics is focusing on that piece. [Providers] need to understand the sensitivity and cash flow now more than ever, right?” he says. “In the case of denial management, I think it's taken a backseat in general.”
Seefeld adds that providers now recognize the importance of virtualization as it pertains to revenue cycle and effectively managing denials. Having the ability to tap into revenue cycle processes once doors were shuttered during the COVID lockdown proved a game changer for many organizations. “Providers know that they have to have a flex model going forward, as in they have to offer their people work-at-home or hybrid models,” Seefeld says. “If anything, the last year has taught us that we can be way more efficient in most cases at home. But you can't send people home if you don't have ways to monitor their effectiveness.”
A Glance Into the Future
Youmans says providers should expect the COVID billing landscape to continue to evolve. Along with the approval of additional vaccines and monoclonal antibody infusions, more encounters will deal with the virus’ long-term effects. Consequently, additional codes will need to be created along with billing rules and requirements.
Brocato suggests that the initial cooperation that the industry has seen with payers will shift to more active scrutiny. “I think there are a lot of payers who are honestly hesitant to deny a COVID claim because it’s just bad PR at this point,” she says. “What we are going to see next is not so many claim-level denials but rather those audits start to happen.” Seemingly right on cue, the Office of Inspector General recently announced its plans to audit hospital payments related to COVID-19 discharges under the CARES Act.
Brocato points to a variety of situations where issues could arise, including patients having symptoms but not testing positive or providers gaining access to test results that are performed at another location. “I think the next level of denials that we start seeing from payers is that there was no positive COVID test result,” she says. “Then providers will have to appeal it, and I think they'll probably win in some cases, and in some cases, maybe not.”
Goessel points out that denials directly related to COVID are beginning to trend up as payers bring in third parties to mine specific diagnoses. “The payers, whether it be the feds or commercial payers, are starting to develop algorithms—predictive algorithms for where the supportable denials are,” she says. “In one sense, that’s good news because you don't want a fishing expedition that takes up your hospital’s time.”
— Selena Chavis is a Florida-based freelance journalist whose writing appears regularly in various trade and consumer publications, covering everything from corporate and managerial topics to health care and travel.
NEW POST–COVID-19 CODE COMING SOON
The World Health Organization (WHO) recently introduced a new ICD-10 code (U09.9), naming it, “Post–COVID-19 condition, unspecified.” Expected to go live October 1, WHO’s instructional note says, “This optional code serves to allow the establishment of a link with COVID-19. This code is not to be used in cases that still are presenting COVID-19.”
According to Tracey Goessel, MD, CEO and cofounder of FairCode Associates, health care organizations will be instructed to “code first the specific condition related to COVID-19, if known, such as chronic respiratory failure, J96.1-, loss of smell and taste, R43.8.”
In early March, the ICD-10 Coordination and Maintenance Committee Meeting at the Centers for Disease Control and Prevention included discussion of the new code and the following Q/A:
Question: “Can we get clarification on terminology of sequelae, residual, h/of, post COVID. Even with this, physicians don't speak coding, so this is another issue to address. Ex. History of recent COVID (couple of weeks) now here with chronic respiratory failure but no active infection despite positive COVID test this admission.”
Answer: “If there is description of a sequela of COVID-19, a residual condition following COVID-19, or a post–COVID-19 condition, then the new proposed code would be used. If there is a history of COVID-19, without a current related condition, then it would be appropriate to assign the code Z86.16, Personal history of COVID-19. If there is a current infection or recurrent infection with COVID-19, then it would be appropriate to assign the code U07.1, COVID-19. If there is a lack of clarity in the clinical record, then it would be appropriate to query the provider.”
Goessel notes that the upcoming codes for post–COVID-19 conditions will require physician education and are likely to generate plenty of queries. “We do not know what the significance this code will have for DRG [diagnosis-related group] assignment as of yet, but [we] will study the issue as soon as the code works with an encoder,” she says.