Insights

COVID-19 and Epic: Patient Friendly Billing Guide


On March 12, 2020, in a primetime coronavirus address, President Trump stated that health insurance industry leaders had agreed to “waive all copayments for coronavirus treatments.” Shortly thereafter, coronavirus patients began to complain to the media about health systems billing them for coronavirus testing and treatment.

Given the international attention focused on the COVID-19 pandemic and the recent sensitivity revolving around incorrectly billing patient responsibility, clients should consider avoiding collection of patient responsibility for COVID-19-related services, including holding statements until there is more clarity around what patients will owe.

Ensemble recommends that clients take the following steps:

  • Create a reason code for POS Non-Payment or Non-Collection. Several of our clients use custom items built into registration workflows, while other use the standard non-collection reason category list to track this. We recommend adding a reason of “COVID-19” to this category list and training staff responsible for collecting POS payments on when to select this value.

  • Configure a CDM code in the procedure master file specific to the new COVID-19 CPT code, 87635. If certain payers require a charge using a HCPCS Level II code, you may need to set up alternate CPT code logic in the procedure master file.

  • Work with your coding team to identify diagnosis codes that may indicate the presence of COVID-19 and make sure they are built in your diagnosis code master file. Ensemble recommends that our clients at least consider B97.29, Z03.818, Z20.828, and U07.1 as diagnoses used for potential Coronavirus cases.

  • Create billing indicators that indicate if a patient has been tested, diagnosed, or has the COVID-19 POS collection status. Build a system actions to apply the billing indicators based on the presence of

    • The previously mentioned procedure code for patients that have been tested

    • The diagnosis codes for patients that have been diagnosed

    • The POS Collection Status for patients that have been flagged by an associate during the POS collection process. NOTE: SBO organizations will want to be sure to also flag PB-only HARs.

  • Single Billing Office (SBO) organizations should create a statement skip reason and associated rule looking for the presence of the previously created billing indicators.

  • Non-SBO organizations will need to configure a PB statement intervention that looks for the COVID-19 CPT code, diagnoses, and POS non-collection status to hold PB statements, in addition to the HB statement skip configuration.

    Please note the following before starting your Epic build:

  • The qualification criteria mentioned above are intentionally conservative to err on the side of billing patient responsibility correctly. This same rule criteria should not be used for reporting the number of confirmed COVID-19 cases.

  • The configurations described in this document may require modification if CMS releases new guidelines regarding COVD-19.

  • Each client’s Epic environment is different. All build must be thoroughly tested before it is moved to Production.

  • These are complex and rapidly evolving issues, and it is not possible for all of the factors that may impact whether these procedures are suitable to be considered here. These suggestions should be carefully scrutinized by your organization to independently determine if they are appropriate for implementation. These recommendations do not create a contractual relationship and Ensemble is not responsible for any losses associated with implementing these procedures. You should consult with your revenue cycle provider about your organization’s individual circumstances. For further information regarding these issues, contactSolutions@ensemblehp.com.

COVID-19 Facility Coding Grid

CPT/HCPCS Codes for Labs

 

CPT/HCPCS Code

 

CPT Description

 

U0001

 

2019 Novel Coronavirus Real Time RT-PCR Diagnostic Test Panel at a CDC lab

 

U0002

 

2019-nCoV Coronavirus, SARS-CoV-2/2019-nCoV (COVID-19) using any technique, multiple types or subtypes (includes all targets) at a non-CDC lab

 

87635

 

Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), amplified probe technique

Diagnosis Codes:

These are common diagnosis codes seen with COVID-19 (but is NOT all inclusive)

 

Diagnosis Code

 

Diagnosis Description

 

Rules

 

U07.1

 

COVID-19

 

  • Effective on April 1st

  • Should be sequenced first in most scenarios

  • Only to be used for confirmed cases (per CDC)

  • Can be used for physician documentation of a “pre-sumptive positive” test (per AHA)

  • Cannot be used for probable, suspected, etc.

 

B97.29

 

Other coronavirus as the cause of diseases classified elsewhere

 

  • To be used for COVID-19 prior to

    April 1st (but is not specific to COVID-19).

  • Not to be used in addition to U07.1

 

Z03.818

 

Encounter for observation for suspected exposure to other biological agents ruled out

 

  • A code from category Z03 is assigned when a person is suspected of having a condition, without signs or symptoms, and after examination and observation, the condition is ruled out.

  • If a definitive diagnosis exists, then it should be coded instead

  • If other (non-related) signs/symptoms exist, then those should be coded.

 

Z20.828

 

Contact with and (suspect-ed) exposure to other viral communicable diseases

 

  • For someone with no signs/symptoms but they have been exposed to someone with COVID-19

 

Common DRGsBEFORE APRIL 1st

Please note that COVID-19 will not link to a specific DRG as the scenario will vary by patient. That being said, the most common DRGs that we will see are as follows:

 

MS-DRG

 

FY 2020 FINAL

Post-Acute DRG

 

FY 2020 FINAL

Special Pay DRG

 

MDC

 

TYPE

 

MS-DRG Title

 

Weights

 

Geometric mean LOS

 

Arithmetic mean LOS

177

Yes

No

04

MED

RESPIRATORY INFECTIONS & INFLAMMATIONS W MCC

1.8912

5.5

6.9

178

Yes

No

04

MED

RESPIRATORY INFECTIONS & INFLAMMATIONS W CC

1.2433

4.2

5.1

179

Yes

No

04

MED

RESPIRATORY INFECTIONS & INFLAMMATIONS W/O CC/MCC

0.8661

3.1

3.8

190

Yes

No

04

MED

CHRONIC OBSTRUCTIVE PUL- MONARY DISEASE W MCC

1.1440

3.6

4.5

191

Yes

No

04

MED

CHRONIC OBSTRUCTIVE PUL- MONARY DISEASE W CC

0.8928

3.0

3.6

 

192

 

Yes

 

No

 

04

 

MED

CHRONIC OBSTRUCTIVE PUL- MONARY DISEASE W/O CC/ MCC

 

0.7092

 

2.4

 

2.9

193

Yes

No

04

MED

SIMPLE PNEUMONIA & PLEURI- SY W MCC

1.3335

4.2

5.2

194

Yes

No

04

MED

SIMPLE PNEUMONIA & PLEURI- SY W CC

0.8886

3.2

3.8

195

Yes

No

04

MED

SIMPLE PNEUMONIA & PLEURI- SY W/O CC/MCC

0.6821

2.6

3.0

196

Yes

No

04

MED

INTERSTITIAL LUNG DISEASE W MCC

1.6754

4.8

6.2

197

Yes

No

04

MED

INTERSTITIAL LUNG DISEASE W CC

1.0215

3.2

4.0

198

Yes

No

04

MED

INTERSTITIAL LUNG DISEASE W/O CC/MCC

0.7550

2.4

2.9

199

No

No

04

MED

PNEUMOTHORAX W MCC

1.7941

5.2

6.7

200

No

No

04

MED

PNEUMOTHORAX W CC

1.0821

3.3

4.2

201

No

No

04

MED

PNEUMOTHORAX W/O CC/MCC

0.7180

2.4

3.0

202

No

No

04

MED

BRONCHITIS & ASTHMA W CC/ MCC

0.9480

3.0

3.7

203

No

No

04

MED

BRONCHITIS & ASTHMA W/O CC/MCC

0.6938

2.3

2.8

204

No

No

04

MED

RESPIRATORY SIGNS & SYMP- TOMS

0.8125

2.2

2.8

205

Yes

No

04

MED

OTHER RESPIRATORY SYSTEM DIAGNOSES W MCC

1.6342

4.1

5.6

206

Yes

No

04

MED

OTHER RESPIRATORY SYSTEM DIAGNOSES W/O MCC

0.8725

2.4

3.1

 

207

 

Yes

 

No

 

04

 

MED

RESPIRATORY SYSTEM DIAG- NOSIS W VENTILATOR SUP- PORT >96 HOURS

 

5.7356

 

12.0

 

14.1

 

208

 

No

 

No

 

04

 

MED

RESPIRATORY SYSTEM DIAG- NOSIS W VENTILATOR SUP- PORT <=96 HOURS

 

2.4841

 

4.9

 

6.8

870

Yes

No

18

MED

SEPTICEMIA OR SEVERE SEPSIS W MV >96 HOURS

6.3243

12.3

14.3

871

Yes

No

18

MED

SEPTICEMIA OR SEVERE SEPSIS W/O MV >96 HOURS W MCC

1.8663

4.8

6.2

872

Yes

No

18

MED

SEPTICEMIA OR SEVERE SEPSIS W/O MV >96 HOURS W/O MCC

1.0393

3.6

4.3


Common DRGsAFTER APRIL 1st

The ICD-10 MCE Version 37.1 R1 uses edits for the ICD-10 codes reported to validate correct coding on claims for discharges on or after April 1, 2020.

The ICD-10 MS-DRG Grouper software package to accommodate this new code, Version 37.1 R1, is effective for discharges on or after April 1, 2020.

Assignment of new ICD-10-CM diagnosis code U07.1, COVID-19, is as follows:

 

MS-DRG

 

FY 2020 FINAL

Post-Acute DRG

 

FY 2020 FINAL

Special Pay DRG

 

MDC

 

TYPE

 

MS-DRG Title

 

Weights

 

Geometric mean LOS

 

Arithmetic mean LOS

 

177

 

Yes

 

No

 

04

 

MED

 

RESPIRATORY INFECTIONS & INFLAMMATIONS W MCC

 

1.8912

 

5.5

 

6.9

 

178

 

Yes

 

No

 

04

 

MED

 

RESPIRATORY INFECTIONS & INFLAMMATIONS W CC

 

1.2433

 

4.2

 

5.1

 

179

 

Yes

 

No

 

04

 

MED

 

RESPIRATORY INFECTIONS & INFLAMMATIONS W/O CC/MCC

 

0.8661

 

3.1

 

3.8

 

791

 

No

 

No

 

15

 

MED

 

PREMATURITY W MAJOR PROBLEMS

 

3.8062

 

13.3

 

13.3

 

793

 

No

 

No

 

15

 

MED

 

FULL TERM NEONATE W MAJOR PROBLEMS

 

3.9097

 

4.7

 

4.7

 

974

 

No

 

No

 

25

 

MED

 

HIV W MAJOR RELATED CONDITION W MCC

 

2.6739

 

6.3

 

8.7

 

975

 

No

 

No

 

25

 

MED

 

HIV W MAJOR RELATED CONDITION W CC

 

1.3420

 

4.1

 

5.5

 

976

 

No

 

No

 

25

 

MED

 

HIV W MAJOR RELATED CONDITION W/O CC/MCC

 

0.9142

 

3.0

 

3.9

 

These materials are for general informational purposes only. These materials do not, and are not intended to, constitute legal or compliance advice, and you should not act or refrain from acting based on any information provided in these materials. Please consult with your own legal counsel or compliance professional regards specific legal or compliance questions you have.

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