By Margaret Cerna, Senior Consultant
HealthCare Information Management, Inc.
Responding to COVID-19 requirements
Claims processing decision makers are faced with unprecedented challenges and may be evaluating and putting their processes to the test to ensure they are ready to receive and process COVID-19 claims. They must determine if they are missing some important actions that need to be addressed or implemented in order to quickly and effectively identify COVID-19 claims based on requirements outlined by the Centers for Medicare & Medicaid Services (CMS) and by the Centers for Disease Control and Prevention ( CDC). While many have faced the first wave, now is the time to prepare for the second wave and ensure they have the appropriate processes in place.
The topics in this white paper are intended to provide information on how you as a claims processing decision maker can:
a) Identify these claims
b) Determine system implementation and configuration needs
c) Locate additional reference resources on how to prepare for COVID-19 and its associated claim processing requirements, including the waiving of cost share
d) Develop processes for tracking and reporting of these claims
How to identify these claims?
The CDC, working in conjunction with the National Center for Health Statistics, the American Health Information Management Association, the American Hospital Association, and the Centers for Medicare & Medicaid Services have developed a guide for diagnosis and other codes to be used with COVID-19.
What follows is a summary of that information as of the date of publishing for this paper, and how it might appear on a claim being submitted to your organization for processing and payment. Neither this summary nor the guide published by the CDC are intended to be a substitution for professional medical advice, diagnosis, or treatment.
Codes to look for on claims
The most common signs and symptoms of infection include respiratory symptoms, fever, cough, shortness of breath and breathing difficulties. In cases of suspected, possible, or inconclusive cases of COVID-19 should be assigned a code that explains the reason for the encounter. There is no doubt the rules and regulations are seemingly changing every day as new information emerges from this highly contagious disease, making coding, pricing, and tracking more challenging than usual. Outlined below are the recently released coding guidelines for COVID-19 infections:
| Code | Description |
|---|---|
|
89 & B97.29 |
Pneumonia 89 and other Coronavirus as the cause of diseases classified elsewhere B97.29 |
|
8 & J40 |
Acute Bronchitis 8 confirmed as due to COVID-19 and due to other specified organisms, such as Bronchitis J40 not otherwise specified (NOS) due to the COVID-19 |
|
J22 |
Unspecified acute lower Respiratory Infection |
|
8 |
Other specified respiratory disorders |
|
J80 |
ARDS cases that may develop in conjunction with COVID-19 |
|
818 |
Cases where there is a concern about a possible exposure to COVID-19 |
|
|
Vaping-related disorder |
|
1 |
Positive testing of COVID-19 |
|
828 |
Contact with and (suspected) exposure to other viral communicable diseases |
|
R05 |
Cough |
|
02 |
Shortness of breath |
|
9 |
Fever Unspecified |
Note: Claims received using the following diagnosis may require a manual review. Diagnosis code B34.2-Coronavirus infection unspecified, would in general not be appropriate for COVID-19, because the cases have universally been respiratory in nature, so the site would not be “Unspecified”. If the provider documents “suspected”, “possible” or “probable” COVID-19, they should not be assigning code B97.29, but rather the claim should have a code(s) explaining the reason for the encounter (such as fever, or Z20.828).
System configuration and internal processing
Similar to the usual handling of any regulatory or compliance mandate update, the Claims and System Configuration teams must collaborate to interpret the language, determine how to address configuration, and then proceed with the System Configurations and Operational decisions, revisions, changes, training, and documentation within the organization. Here are a few updates that have recently been released by CMS, CDC, and the AMA organization:
- Add new CPT procedure codes and their descriptions specific to COVID-19
- Add new ICD 10 diagnosis codes and their descriptions specific to COVID-19
- Update timely filing requirements
- Creating new fee schedule(s)
- Creating new fee set assignment(s)
- Updating sequestration reduction rules
- Updating member plan benefits
For the latest information and any more current updates, please reference the following websites:
https://www.ama-assn.org/topics/cpt-new-codes
COVID-19 Claim Payment, Tracking, and Reporting
Managing claim data is a common concern for any Claims Manager or Claims Director. We all want a claims operation that is member focused and cost-effective. We want the ability to adjudicate claims quickly and effectively, track and report the data to internal and external stakeholders. These three factors can be stressful and can cause a positive or negative impact on business revenue if it is not managed correctly. Automation is a great way to cut down on manual claim workload and ensure accuracy.
CLAIM PAYMENT
Automation can help you efficiently and effectively identify claims related to COVID-19 and help you process them faster.
CLAIM TRACKING
Using elements from this white paper and those created in the claim payment system, Claim Inventory reports can be produced to track and monitor claims.
REPORTING DATA
Reports can be produced using current software applications such as Crystal, SSMS, & Excel to track COVID-19 related claims.
Conclusion
We hope this paper has provide an overview of what to expect with the processing of COVID-19 related claims. It is critical that your organization have a clear understanding of where it stands in terms of readiness. If you are confident that you are prepared, then congratulations. If you are not prepared to declare readiness just yet, and need help understanding where to start, or decide on what strategies may be right for you, we are here to help.
It is difficult for managers to balance the demand of new healthcare requirements, claim productivity, and performance all at once. We are here to help ease some of the burden and give you the freedom and opportunity to focus on other duties and deadlines. Do not let these changes slow you down. We are here to help you prepare for receipt and processing of COVID-19 claims. If you are interested in learning more about the services and robotic automation claims processing solutions that we offer, please feel free to reach out to us at info@HCIM.com
