In May we opened up our Advanced Training session, “COVID-19: MDS Coding and Documentation FAQs,” to the public and we received a volley of great questions that we didn’t have enough time to answer thoroughly. Below are my responses to the questions submitted during our live session. You can also check out the session recording and we‘ve been compiling all our COVID-19 resources specific to skilled nursing care for easy access.
Q: We had a resident who was tested as she had symptoms, but the test results did not come back in a timely manner. She was put on isolation and all precautions were followed. The test finally came back inconclusive. The physician diagnosed presumptively positive COVID-19. We had admitted her to MED A just like all the other residents that had come back positive as she had the symptoms. Since the new guidelines came out, we took her off MED A. But we all believed as the doctor did, that she did have it. Could we have left her on MED A?
A: From your description it sounds like you could have continued to skill the resident for as long as she was at that level of services (isolation, precautions, assessment and monitoring etc.). Keep in mind that a diagnosis or lack thereof isn’t the sole deciding factor of whether or not to cover under skilled Medicare. If the resident’s illness requires daily skilled nursing care that is medically necessary, this would justify the skilled coverage even though you wouldn’t be able to code U07.1 as the primary diagnosis.
Q: I have a resident who was discharged to hospital, was tested for COVID-19 and the first test was falsely positive. Two more tests were done and came out negative. Resident came back to the SNF in an observation room for 14 days by herself. Do I code the diagnosis that she got tested for COVID-19 even though it was negative?
A: From this description, you wouldn’t code the COVID-19 diagnosis because there were two negative results following the positive one. This would fit the CDC’s criteria for discontinuing isolation precautions. Here’s the CDC guidance for your reference. Of course, this should also be confirmed with the physician since their documentation drives the diagnosis.
Q: We have numerous residents that went to the hospital and tested for COVID-19 and results were not detected or negative. Do I code the Z-code?
A: Yes. This is from the CDC’s ICD-10 guideline I referenced on the webinar: “For cases where there is an actual exposure to someone who is confirmed or suspected (not ruled out) to have COVID-19, and the exposed individual either tests negative or the test results are unknown, assign code Z20.828, Contact with and (suspected) exposure to other viral communicable diseases. If the exposed individual tests positive for the COVID-19 virus, see guideline a).”
Q: In regard to the COVID waiver, we had a lady who was sent to the ER from an assisted living. It was determined she had a UTI, was deconditioned, and could not go to back to AL so she was admitted to the SNF. She did receive therapy which is a skilled service. Does she qualify for Med A under the COVID-19 waiver? The hospital did not need beds for someone with COVID-19?
A: We believe the answer is yes in this case. Although the hospital did not need to free up inpatient beds, it could be that she was discharged from the ER to limit the potential for spread of the virus. In other words, related to the COVID-19 emergency but not a COVID case (the COVID diagnosis is not required to exercise the waiver).
Q: When do you code fever, cough, dyspnea, etc.?
A: How the symptoms would be coded depends on whether the resident has tested positive. The fever would be coded in J1550A and the dyspnea in J0110 regardless. You can assign the ICD-10 codes if needed according to the CDC guidelines:
f) Signs and symptoms without definitive diagnosis of COVID-19 For patients presenting with any signs/symptoms associated with COVID-19 (such as fever, etc.) but a definitive diagnosis has not been established, assign the appropriate code(s) for each of the presenting signs and symptoms such as:
- R05 Cough
- R06.02 Shortness of breath
- R50.9 Fever, unspecified
If a patient with signs/symptoms associated with COVID-19 also has an actual or suspected contact with or exposure to someone who has COVID-19, assign Z20.828, Contact with and (suspected) exposure to other viral communicable diseases, as an additional code. This is an exception to guideline I.C.21.c.1, Contact/Exposure
Q: What diagnosis should be coded on the MDS if skilling for observation and management of possible COVID-19 symptoms? What would be a PDPM code that’s not Return to Provider?
A: While we can’t suggest a specific code for this, we can recommend that you and the physician discuss the primary reason for SNF skilled care (i.e., are there any other skilled needs, or is the observation and management the only one?). There may be another code you can use if the resident has other comorbidities, such as COPD with acute exacerbation. If you haven’t already, please download the most current ICD-10 mapping files that were updated effective April 1.
Q: If a resident is symptomatic and is being tested but the positive test result comes back after the ARD, can that be coded as isolation as long as all the other criteria are met?
A: In this case, you may be able to code isolation with the proper documentation during the look-back period. The RAI coding definition says, “active infection (i.e., symptomatic and/or have a positive test and are in the contagious stage) with highly transmissible or epidemiologically significant pathogens that have been acquired by physical contact or airborne or droplet transmission” [emphasis added]. The “and/or” indicates that symptoms are sufficient, particularly since there was in fact a positive test result that was pending at the time of the ARD.
Q: We have a resident who meets all of the 4 criteria for isolation and is in the single room for 3 days in the look back period. After the ARD, the facility then cohorts the resident. Do we HAVE to do an IPA after the isolation is completed? I have heard that an IPA must be done… but we all know that an IPA is optional.
A: An IPA is always optional. As of now, CMS has not made an exception to this rule. After the isolation period ends, make sure to continue the resident on skilled coverage only for as long as their level of care warrants.
Q: For residents in the facility as a whole after we have a confirmed case of the COVID-19 in the facility, can we code the Z20.828 for all residents since we do not know who was exposed or not?
A: You should be able to code the diagnosis (with physician’s documentation) as long as you have determined that there is a likelihood of exposure. The diagnosis would then be updated or resolved once it is determined whether the exposed resident was infected:
For cases where there is an actual exposure to someone who is confirmed or suspected (not ruled out) to have COVID-19, and the exposed individual either tests negative or the test results are unknown, assign code Z20.828, Contact with and (suspected) exposure to other viral communicable diseases. If the exposed individual tests positive for the COVID-19 virus, see guideline a.
Q: Per Noridian, for the Residents who have exhausted benefits and started their 60-day wellness, they will deny any claim unless the resident has a diagnosis of COVID19 under the 1135. Is there any clarification on this?
A: The Medicare Benefit Policy Manual (Chapter 8) states, “While a patient’s particular medical condition is a valid factor in deciding if skilled services are needed, a patient’s diagnosis or prognosis should never be the sole factor in deciding that a service is not skilled.” There has so far been no transmittal from CMS stating otherwise. This document from the New York State Health Facilities Association may be helpful. It’s an extremely detailed compilation of sources from CMS, the CDC, and AHCA related to the waiver.