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Does a patient need to have a positive COVID-19 lab test in order for us to receive the additional 20 percent increase of the MS-DRG weighting factor for our Medicare inpatient COVID-19 claims?

Within its revised MLN Article, SE20015, CMS announced that for admissions occurring on or after September 1, 2020, patients will be required to have a documented positive COVID-19 lab test in order for facilities to receive the additional 20 percent increase to the weighting factor for inpatient COVID-19 claims. Per the Article, the viral testing can be performed by an entity other than the hospital (i.e. governmental testing site, urgent care center, etc.) however, the positive result must be recorded in the patient’s hospital medical record in order to satisfy the documentation requirement. The positive test can be obtained either during the hospital inpatient admission or within 14 calendar days prior to admission.

CMS states that it may conduct post-payment medical reviews to confirm a positive COVID-19 laboratory test is present within the medical record. If a positive test is not documented within the record, CMS will recoup any additional payment resulting from the 20 percent increase to the MS-DRG relative weight. To avoid recoupments for COVID-19 claims without a positive COVID-19 test result, CMS advises hospitals to notify their MAC to bypass the 20 percent increase to the MS-DRG relative rate, at the time of claim submission.

CMS MLN Matters Article SE20015:
https://www.cms.gov/files/document/SE20015.pdf