Reimbursement Methodologies During the COVID-19 Public Health Emergency

April 13, 2021

Reimbursement Methodologies During the

COVID-19 Public Health Emergency


The last year saw unprecedented changes to healthcare reimbursement. Many facilities have dealt with COVID-19 on the patient care side, which includes staffing, availability of personal protective equipment, and bed availability while trying to understand and keep up with the reimbursement requirements and changes put in place by the federal government during the declared Public Health Emergency (PHE).

The Coronavirus Aid, Relief, and Economic Security (CARES) Act was enacted on March 27, 2020. Although this package was comprised of aid to people and businesses in the United States, it also included changes for healthcare facilities. We saw immediate changes to specific guidelines for telemedicine visits to accommodate care to both urban and rural patients, and various participation waivers for community and rural hospitals. One of the largest changes was the temporary payment policy implemented to off-set costs associated with caring for COVID-19 patients, since it was quickly recognized these patients were higher risk and more resource intensive. Certain DRG weights were increased by 20%, and this mechanism will continue through the end of the COVID-19 emergency declaration. The presence of specific ICD-10-CM codes are required for additional reimbursement to apply.

During this time, we also experienced an influx of new reporting requirements, namely a new ICD-10-CM code to specifically identify the presence of SARS CoV-2 virus and various coding guidelines for reporting this.  Several laboratory tests and related services for COVID-19 were created or redefined, along with the appropriate administration, coding and reporting guidelines for these.

On November 9, 2020 an Emergency Use Authorization (EUA) was issued by the FDA for two monoclonal antibodies— a proven effective in treatment of COVID-19. Facilities were required to add these HCPCS codes to their chargemaster and ensure appropriate code assignment for reimbursement. At the same time, the American Medical Association released new codes for COVID-19 vaccines and their associated administration codes. Soon after, the IPPS New Technology Add-On Payment was instituted, which provides additional payments for cases utilizing new medical services or technologies.

The New COVID-19 Treatments Add-On Payment, also known as NCTAP was developed due to recognition that not only do COVID-19 patients tend to have a higher resource utilization, some of the new-technology resources are more costly than traditional medications and treatments. Remdesivir infusion and administration of convalescent plasma were designated as treatment standards. Through the NCTAP, facilities who administered these treatments are eligible for an even higher reimbursement than the initial 20% increase on COVID-19 related DRGs. This will also apply to any subsequent drugs or biological products designed to treat the SARS CoV-2 virus as they become available during the PHE.

CMS gave guidance on procedure codes required:

CMS will use ICD-10-PCS procedure codes XW033E5 (Introduction of Remdesivir Anti-infective into Peripheral Vein, Percutaneous Approach, New Technology Group 5) and XW043E5 (Introduction of Remdesivir Anti-infective into Central Vein, Percutaneous Approach, New Technology Group 5) to identify cases using Remdesivir and ICD-10-PCS procedure codes XW13325 (Transfusion of Convalescent Plasma (Nonautologous) into Peripheral Vein, Percutaneous Approach, New Technology Group 5) and XW14325 (Transfusion of Convalescent Plasma (Nonautologous) into Central Vein, Percutaneous Approach, New Technology Group 5) to identify cases using convalescent plasma.

There are certain criteria that must be met to qualify for the add-on payment under the IPPS:

  1. The case must include the use of a drug or biological product authorized to treat COVID-19
    1. Currently there are only 2 drug or biological products that meets these criteria – Veklury (Remdesivir) and COVID-19 convalescent plasma
  2. The case must also be eligible for the 20% increase in the weighting factor for the assigned MS-DRG for an individual diagnosed with COVID-19 discharged during the PHE for COVID-19.
  3. The operating cost of the case must exceed the operating Federal payment under the IPPS, including the add-on payment.
    1. The cost of the case is determined by multiplying the covered charges by the operating cost-to-charge ratio

Also note that all cases are subject to post-payment review by CMS to confirm there is presence of a positive COVID-19 test along with the three criteria above.  If a positive test is not part of the encounter-specific medical record, the NCTAP will be recouped.

From an administrative standpoint, it is extremely important that facilities are reimbursed at the highest level for the care provided to COVID-19 patients.  Although the new technology ICD-10-PCS procedure codes for infusion of Remdesivir or administration of convalescent plasma does not change the MS-DRG assignment, presence of the newly developed procedure codes and the documentation supporting code assignment is important for correct reimbursement. Because these are new codes, small audits performed on inpatient encounters have revealed missed opportunities, as either one or both codes have not been assigned. This could be due to coder error or documentation issues.

In this ever-changing environment, facilities are urged to conduct their own internal audits to be certain medical record documentation and code application is accurate and complete for optimal reimbursement.




Robyn McCoart, RHIT– Managing Auditor