AHA Requests Further Guidance on the HRSA COVID-19 Uninsured Program

Dear Administrator Engels:

On behalf of our nearly 5,000 member hospitals, health systems and other health care organizations, our clinical partners – including more than 270,000 affiliated physicians, 2 million nurses and other caregivers – and the 43,000 health care leaders who belong to our professional membership groups, the American Hospital Association (AHA) requests further guidance on the Health Resources and Services Administration (HRSA) COVID-19 Uninsured Program. Responses to these issues will be essential for health care providers to successfully use the program beginning next week.

1. Operationalizing the Claims Reimbursement to Health Care Providers and Facilities for Testing and Treatment of the Uninsured. In order to direct payments accurately and efficiently, we urge HRSA to state that providers may use the COVID-19 diagnosis codes in both the primary and secondary diagnosis fields on the hospital claim. Providers should identify claims for testing and treatment of COVID-19 using the correct ICD-10-CM diagnosis codes in any diagnosis field following the ICD-10-CM Official Guidelines for Coding and Reporting issued for the coding of COVID-19; otherwise providers will be faced with the dilemma of having to violate HIPAA code set rules if they want to be reimbursed for the care of the uninsured.

We believe the HRSA guidance and frequently asked questions misstate the appropriate diagnosis code by stating that reimbursement will be made for testing and services “with a primary COVID-19 diagnosis.” Specifically, we recommend the following codes be used:

• For discharges of an individual diagnosed with COVID-19, patients should be identified by the presence of the following International in any diagnosis field based on the applicable coding guidelines in effect at the time of the encounter:
  • B97.29 (Other coronavirus as the cause of diseases classified elsewhere) for discharges occurring on or after February 4, 2020, and on or before March 31, 2020, based on the Supplement guidelines. Code B97.29, is precluded from being a first-listed or principal diagnosis by the ICD-10-CM Tabular instructions and the Official Guidelines for Coding and Reporting which are part of the HIPAA code set standard.
  • U07.1 (COVID-19) for discharges occurring on or after April 1, 2020, through the duration of the COVID-19 public health emergency period, based on the updated guidelines for the new code.
  • There are several situations where ICD-10-CM code U07.1, COVID-19, would be a secondary diagnosis code, or a different ICD-10-CM code would be more accurate. For example, for a patient admitted with sepsis due to COVID-19, or for an obstetrics patient with COVID-19, the Coding Guidelines instruct that code U07.1, COVID-19 would be a secondary diagnosis and not the primary diagnosis.
     
• For testing-related visits, including specimen collection, diagnostic and antibody testing, if the results are negative, inconclusive or not available at the time of testing, they would not be assigned a primary diagnosis of U07.1, COVID-19 diagnosis code. Instead, any one of the following codes would be the correct diagnosis code depending on the circumstances:
  • Z01.84, Encounter for antibody response examination
  • Z03.818, Encounter for observation for suspected exposure to other biological agents ruled out
  • Z11.59, Encounter for screening for other viral diseases
  • Z20.828, Contact with and (suspected) exposure to other viral communicable diseases
  • Z86.19, Personal history of other infectious and parasitic diseases

For example, during the Q&A portion of the “Getting Started with the HRSA COVID-19 Uninsured Program” webinar broadcast of April 30, 2020, an incorrect answer was given for a question of a patient presenting to the emergency department with cough and fever that tested negative for COVID-19. The answer provided was to assign code Z03.818, Encounter for observation for suspected exposure to other biological agents ruled out. This answer is incorrect as it violates the ICD-10-CM Tabular List instructions that codes from this category are “to be used when a person without a diagnosis is suspected of having an abnormal condition, without signs or symptoms, which requires study, but after examination and observation, is ruled out.” Instead, following coding guidelines, such a patient would have been assigned codes for the symptoms of cough and fever, followed by code Z20.828, Contact with and (suspected) exposure to other viral communicable diseases.Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) diagnosis codes 

For additional examples on the usage of ICD-10-CM coding for COVID-19, you may wish to refer to the Frequently Asked Questions jointly developed by the AHA and the American Health Information Management Association, the two non-federal members of the Cooperating Parties responsible for the development of the Official Coding Guidelines.

2. Confirming a Patient’s Uninsured Status. We understand that providers have to check for both enrollment in and eligibility for other forms of coverage. However, a Medicaid eligibility check often takes longer than 30 days. Is it a requirement for providers to submit Medicaid applications prior to submitting the claim to the Program? If so, will the providers be required to wait until the Medicaid application is denied prior to submitting the claim to the program? What happens if, as will likely be the case, the 30-day filing period has expired?

3. Clarifying the COVID-19 Reimbursement Rate. We understand that reimbursement will be set at Medicare rates. The Coronavirus Aid, Relief, and Economic Security (CARES) Act included a 20% add-on to the Medicare diagnosis-related group (DRG) payment for COVID-19 treatment. Is that the rate that HRSA will use, or will it use the DRG rate without the 20% add-on?

4. Clarifying 30-day temporary ID window for claims prior to May 6. According to HRSA guidance, the COVID-19 Uninsured Program will reimburse for testing and treatment for uninsured individuals on or after February 4, 2020. However, the program portal will only assign patients temporary IDs, necessary for submitting claims, for 30 days from date of service or date of discharge for facility inpatient services. Unless addressed, this inconsistency will preclude most claims prior to the opening of the portal from being submitted. We urge HRSA to clarify that claims incurred prior to the portal opening can be given temporary IDs for 30 days following the portal opening.

We appreciate the work of the agency to provide coverage for the uninsured and look forward to continuing to work with you during this critical time to protect the health of our nation.

Sincerely,

Ashley Thompson
Senior Vice President, Public Policy Analysis and Development

Cc: Seema Verma, Administrator, Centers for Medicare & Medicaid ServicesAshley D. Bieck, Vice President, National Provider Advocacy, UnitedHealthcare