Optimizing Your Reimbursement During COVID-19

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What’s the best way to maintain your money in the midst of a pandemic?

A Novel Threat and Surprising New Challenges:

With the arrival of the COVID-19 pandemic to the United States, Emergency Medicine physicians are realizing that more than just our clinical skills are needed to endure through these difficult times. Affected by opposite ends of this crisis, the financial impact on many physician groups has been devastating.


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In regions with heavy rates of infection, clinicians are faced with increased costs associated with updating facilities, purchasing PPE, and streamlining patient care. Conversely, providers practicing in areas with low rates of infection have been adversely affected by Shelter in Place guidelines and cancelled elective services. ER patient volumes are down an estimated average of 40%. As a result, the financial stress faced by virtually all emergency groups is most unexpected.

Physicians have raised concerns as to how can we survive in this climate. For clinicians in the trenches, there is at least some good news. By optimizing our charting, we can optimize our appropriate reimbursement. This article will show you how to be part of the solution for your own financial recovery.

The “CARES” Act — A Starting Point for Relief:


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First, let’s frame the perspective. The “Coronavirus Aid, Relief and Economic Security Act” was signed into law on March 27, 2020. This fiscal rescue package allocated $100 billion in relief funds to hospitals and healthcare providers in the battle against COVID-19.

Of these funds, $30 billion was delivered immediately to all facilities and providers that received Medicare fee-for-service reimbursements in 2019. The amount allotted to providers was calculated on their share of total Medicare fee-for-service reimbursements for that year — approximately 6.1%. Furthermore, an additional $20 billion is being distributed with overall payments adjusted based on providers’ share of their 2018 net patient revenue.

For the remaining $50 billion of CARES distributions, these will be directed toward providers in regions heavily impacted by this healthcare crisis. Rural practitioners, providers with lower portions of Medicare reimbursement or serving high Medicaid populations, and “providers requesting reimbursement for the treatment of uninsured Americans” will also be included.[1]  It is important to keep in mind that these distributions are payments – not loans, which is one positive light for Emergency physicians.

However, there has been a catch. In order to receive payments, recipients have had to sign an attestation agreeing to the terms and conditions of the CARES distributions. Included in these terms is the requirement that physicians no longer balance bill their out-of-network encounters. This may not have a direct impact on your group, as some states prohibit balance billing already. For other practices, this has been a factor to consider.


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In addition to the CARES Act, there has been another bill – the Families First Coronavirus Response Act – signed into law on March 18, 2020. Both this and the CARES Act mandate that clinicians be reimbursed for the testing and treatment of suspected COVID-19 patients by government and commercial payers. This is where your documentation will be essential to your financial well-being. Revenue cycle management companies and billing agencies will rely on your charting to properly secure your portion of COVID-19 targeted funding and reimbursement.

Here’s How to Chart (and Reimburse) Most Effectively:

In your documentation, strive to clearly identify each and every patient whose evaluation, management, and / or treatment occurs in the context of COVID-19. Here’s one example for your charting:

“This patient was evaluated, managed, and treated in the context of the COVID-19 pandemic. As such, associated resources were utilized in his care.”

Moreover, work to include such a statement in every case where specific resources (PPE, isolation protocols, treatment modalities) are being utilized towards the care of a patient.

Next point – always remember to detail the proper Medical Decision Making and ALL of the service you provide. As with every case, your History of Present Illness sets the stage. When appropriate, highlight the symptoms and context which place a patient in the COVID universe. Also, for these encounters, chart a Differential Diagnosis that reflects your consideration of coronavirus. Here’s how your documentation should look:

“Differential Diagnosis: MI, Pneumonia, Pneumothorax, GERD, Musculoskeletal, Myocarditis, COVID-19, other”

When appropriate, be sure to convey such considerations in your charting to your physician colleagues, medical coders and insurance payers. This is the future of Emergency Medicine reimbursement (before, during and after COVID-19). Always include a differential diagnosis.

Finally, document ancillary testing and diagnoses that pertain to COVID-19. The goal is to make it clear that your services involved consideration of the SARS-CoV-2 virus. Here’s how your documentation should look:

“COVID-19 nasopharyngeal swab – ordered and obtained”

“Diagnosis: 1. Acute Hypoxic Respiratory Failure  2. Suspected COVID-19 Virus Infection. 3. Pneumonia”     

Documenting that you have “ordered” and/or “obtained” testing for COVID-19 is tremendously important for your patients. “No cost sharing” statues for testing (and treatment) are in place that reduce the financial burden on patients for whom COVID-19 testing is ordered or obtained.

Regarding your diagnoses, standard best practice has been to chart the most serious diagnosis first. That being noted, when appropriate, specifying a “COVID-19” (or “Suspected COVID-19”) diagnosis should be a close second in your charting. In order to qualify for targeted funding and specialized reimbursement provisions, it’s essential that your coders and payers readily identify these encounters.

All of This Matters — More Than You Think:

True, charting optimally facilitates your proper funding and reimbursement with COVD-19. It also serves the financial best interests of your patients. What you may not know is that your documentation potentially decreases your medical-legal risk. Some states have enacted COVID-19 liability protection laws – more encouraging news for providers. Without question, Emergency Medicine physicians are being challenged on many fronts by the Coronavirus. Not to worry, we’ll continue to innovate and overcome. Taking ownership of what we can control, we can practice effectively through this pandemic.

Peer reviewed by Jim Blakeman – physician reimbursement, medical coding, and policy development expert. He serves as Executive Vice-President at LogixHealth and also resides on EDPMA’s Quality Coding Documentation Committee. Share your interests and comments: jblakeman@logixhealth.com.

ABOUT THE AUTHOR

Dan Magdziarz, DO, is an emergency physician at Palos Hospital in Chicagoland. He is also CEO and founder of ChartOptima.com: 2018 Emergency Medicine reimbursement teaching website. You can follow on Twitter @EMreimbursement.  Share your interests and comments: dmagdziarz@chartoptima.com.

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