Payer Split-Bill Requirement: Separate Claims to Avoid Edit

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Original story posted on: February 22, 2021

Pay attention to dates associated with the new COVID--19 codes, Z20.822 and Z20.828, to avoid billing errors. 

In December 2020, the Centers for Disease Control and Prevention (CDC) announced six new International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes, developed to capture the disease process of COVID-19 better. These codes were first introduced at the Sept. 8, 2020 Coordination and Maintenance Committee meeting, and have since been approved and made available on Jan. 1, 2021, for reporting purposes. 

There have been multiple code changes and updates related to COVID-19 (SARS-CoV-2) since the beginning of the pandemic. In particular, among the ICD-10-CM diagnosis codes implemented on Jan. 1 is code Z20.822, Contact with and (suspected) exposure to COVID-19, which previously required the code Z20.828. Pay attention to the specific dates associated with Z20.822 and Z20.828, as this will be critical for billing. 

Payers require that a claim be split-billed by year when the claim spans both the 2020 and 2021 calendar years, as it relates to Z20.822 and Z20.828. Though not official payment guidance, providers are discovering that this is the case for the majority of payerss. For instance, if a patient had pre-op testing done, including a COVID screening (Z20.828), in December 2020, with a January 2021 outpatient surgery date, the claim will likely be split-paid by the year. Please reference the specific claim example below:

  • A patient has pre-op testing done, including COVID screening (Z20.828), on Dec. 31, 2020.
  • The patient has outpatient surgery on Jan. 5, 2021.
  • Claim dates are 12/31/20 to 1/5/21 (which includes the pre-op testing and the outpatient procedure on the claim).
  • The coder correctly assigns Z20.828, based on the pre-op COVID screening 2020 date of service.
  • Code Z20.828 edits as an invalid code on this claim with a discharge date in 2021 due to DOS of the COVID test: Dec. 31, 2020.
  • With a 2020 date of the COVID test, you must split out the 2020 charge with Z20.828 and submit a separate claim for the specific 2021 charges to avoid the edit.  

New ICD-10-CM codes implemented Jan. 1, 2021 include the following:

    1. J12.82 - Pneumonia due to coronavirus disease 2019
    2. M35.81 - Multisystem inflammatory syndrome
    3. Z11.52 - Encounter for screening for COVID-19 (please note: this code is not to be used until after the end of the public health emergency)
    4. Z20.822 - Contact with and (suspected) exposure to COVID-19   
    5. M35.89 - Other specified systemic involvement of connective tissue
    6. Z86.16 - Personal history of COVID-19

This unprecedented time of coding updates evidences the critical importance of securing quality and consistent medical coding education for your team. Additionally, in consideration of the expanded documentation, coding, and reporting of COVID-19 encounters, providers will be expected to demonstrate their efforts to be compliant with published guidelines. Engaging a clinical documentation integrity (CDI) team has proven beneficial in helping facilities complete concurrent and retroactive documentation and coding assessments of COVID-19 encounters. These efforts could greatly help in demonstrating compliance in practices, and potentially avoid payers audit recoupments.

There were 27 new ICD-10 codes for COVID-19-related conditions, monoclonal antibodies, and more, that became effective Jan. 1, 2021. The impact COVID-19 has had on medical coding and billing is nothing less than remarkable. It has undoubtedly been a year filled with challenges; however, in addressing these challenges, the industry has discovered opportunities for efficiency and long-term improvements that will extend far beyond the pandemic. 

Programming Note: Listen to Susan Gatehouse report this story live today during Talk Ten Tuesdays, 10 a.m. Eastern.   

 

The January 2021 ICD-10-CM addenda and updated ICD-10-CM Official Guidelines for Coding and Reporting are available on the CDC website:   

https://www.cdc.gov/nchs/icd/icd10cm.htm

Susan Gatehouse, RHIT, CCS,CPC, AHIMA-Approved ICD-10-CM/PCS Trainer

Susan Gatehouse is the founder and chief executive officer of Axea Solutions. An industry expert in revenue cycle management, Gatehouse established Axea Solutions in 1998, and currently partners with healthcare organizations across the nation, to craft solutions for unique challenges in the dynamic world of healthcare reimbursement and data management.

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