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CMS issues new requirement for DRG add-on

The Centers for Medicare & Medicaid Services (CMS) updated its guidance this week related to the 20% inpatient prospective payment system (PPS) diagnosis-related group rate add-on for patients diagnosed with COVID-19. For inpatient admissions occurring on or after September 1, claims eligible for the 20% add-on will be required to have a positive COVID-19 laboratory test documented in patients’ medical records. The test may be performed either during the hospital admission or prior to the hospital admission. Per the guidance, a viral test performed within 14 days of the hospital admission, including a test performed by an entity other than the hospital, can be manually entered into the patient’s medical record to satisfy this documentation requirement. While the inpatient PPS Pricer will continue to apply the 20% adjustment based on appropriate diagnosis codes, the guidance notes that CMS may conduct a post-payment medical review to confirm the presence of a positive COVID-19 test in the medical record.