HRSA Uninsured Reimbursement Program Permits Code Re-sequencing

HRSA is not a HIPAA-covered entity, so the official coding rules do not need to be followed when submitting claims.

EDITOR’S NOTE: On this week’s Monitor Mondays, Dr. Ronald Hirsch discussed the Health Resources & Services Administration (HRSA) program, funded by the Coronavirus Aid, Relief, and Economic Security (CARES) Act, for reimbursement for care provided to COVID-19 patients without insurance coverage. What follows is an article outlining his thoughts.  

This program will pay providers at Medicare rates for care “if the COVID-19 diagnosis is the primary diagnosis.” This poses an issue for patients whose care would normally be coded with a different primary or principal diagnosis, such as a patient with COVID-19 who presents with sepsis; coding rules mandate the primary diagnosis of sepsis. Another such scenario would be if a consultant nephrologist called to see a COVID-19 patient with acute renal failure; the primary diagnosis would be acute renal failure.

Dr. Hirsch went on to note that the HRSA program is not a HIPAA-covered entity, so the official coding rules do not need to be followed when submitting claims. In those instances, the COVID-19 diagnosis can be sequenced first.

A Monitor Mondays listener heard the segment and contacted Dr. Hirsch, noting that coders refer to the first diagnosis as the principal diagnosis, changing the order of codes is not generally permitted, and resequencing the codes will change the DRG and therefore the reimbursement. We asked Dr. Hirsch to respond to this.

“These are very good points,” Hirsch said. “Nothing about this pandemic is normal, and the rules for this HRSA program are no exception. I understand that coders may be reluctant to reorder codes on a claim, but as noted, the HIPAA transaction standards do not apply. The HRSA FAQ even addresses this, stating that ‘the ICD-10-CM Official Coding Guidelines – Supplement for Coding Encounters related to COVID-19 Coronavirus Outbreak do not apply to the HRSA Uninsured COVID-19 program.’”

“I often face this issue with Medicare Advantage plans denying inpatient admissions after discharge, and then allowing the hospital to bill for observation services even when there is no order,” Hirsch explained. “When the utilization review staff pass on this instruction to the coders, the coders and compliance staff are reluctant to (follow it).”

Hirsch asked: when a payer tells you that you can do something, and that will get you paid, why would you say “no?” He further pointed out that, in the Medicare Managed Care Manual, Chapter 4, the Centers for Medicare & Medicaid Services (CMS) even says that “MA plans need not follow original Medicare claims processing procedures. MA plans may create their own billing and payment procedures as long as providers – whether contracted or not – are paid accurately, timely, and with an audit trail.”

“So if HRSA says you do not have to follow coding guidelines, believe them,” Hirsch said.

Hirsch explained that the issue about the DRG assignment is “fascinating,” noting that is true that moving sepsis from the principal diagnosis to a secondary diagnosis may change the DRG to one with a much lower weight. And that should be considered.

“But these claims are for uninsured patients, so the calculation is not which DRG has a higher weight, but whether the payment from HRSA for the DRG using the new code sequencing will be more or less than the payment from the patient if the claim is not submitted to HRSA and instead alternative methods of collection are used, such as using the hospital charity program or billing the patient directly.”

Hirsch speculated during his Monitor Mondays segment that in most instances, taking a “low” DRG payment will far exceed any amount collected directly from the patient.

“If the patient is eligible for any insurance coverage, but has not applied or been approved, the patient could be enrolled in that coverage, (with) a claim submitted with the proper code sequence – and if coverage is given retroactively to cover the admission and payment received, the HRSA payment could then be refunded,” Hirsch said. “The criteria set by HRSA is ‘covered at the time the service is rendered,’ so this is a feasible option.”

According to Hirsch, for physician claims, code sequencing is not an issue in payment. The amount paid is based on the service provided, and not the diagnosis code. The HRSA claim for care of a COVID-19 patient can therefore be submitted with the COVID-19 diagnosis code in the first position, and listed as the primary diagnosis for every line item to HRSA. And once again, if other coverage becomes available, the codes can be “properly” sequenced for that submission.

“It is often difficult to reconcile following one set of rules for one scenario and another set for a similar scenario, and perhaps even more difficult to operationalize it,” Hirsch said. “But when the payer tells you it is allowed, and it is the only way you are going to get paid, it seems the effort will pay off.”

Programming Note: Ronald Hirsch, MD is a permanent panelist on Monitor Mondays. Listen to his live reporting every Monday at 10-10:30 a.m. EST.