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CMS Suspends Most Medicare Fee-For-Service Medical Review

Posted Apr 2, 20208 min Read

Regulatory & Clinical
In This COVID-19 Update:

  • The Toll COVID-19 Takes on Residents, Families and Staff
  • CDC Clinician Outreach and Communication Webinar Tomorrow
  • MDS Isolation Coding Guidance Remains Unchanged
  • CMS Updates PDPM-ICD-10 Mappings for New COVID-19 Diagnosis Code
  • CMS Suspends Most Medicare Fee-For-Service Medical Review

Prepare for the Toll COVID-19 Can Take on Residents, Families and Staff

As we have seen in the outbreak in Washington state, nearly half of all residents infected were hospitalized and approximately 20-25% died. While we are seeing similar widespread outbreaks in some facilities, others are experiencing only a small number of residents infected. Regardless, long term care staff need to prepare for residents becoming ill with COVID-19, possibly needing hospitalization, and unfortunately for some residents, succumbing to the virus. You can take the following steps to help prepare.

CDC’s Clinician Outreach and Communication Activity Call Tomorrow

During this COCA Call, clinicians will provide an overview of the clinical characteristics of COVID-19 patients, including case presentations of critically ill adults and clinical management challenges, and summarize recently published guidelines on clinical management of critically ill adults.

Clinical Management of Critically Ill Adults with Coronavirus Disease 2019 (COVID-19)
Thursday, April 2 | 2:00 p.m. –3:30 p.m. (EDT)
Learn more about how to join.

MDS Isolation Coding Guidance Remains Unchanged

Members have been asking if CMS has made any changes to the MDS coding guidance associated with item O0100M – Isolation for active infectious disease (does not include standard precautions) located in Chapter 3 of the MDS 3.0 RAI Manual v 1.17.1 October 2019 . Below is an excerpt from the current coding requirements describing the four specific conditions that must be met to check the O0100M item box for the presence of isolation for active infectious disease.

Code for “single room isolation” only when all of the following conditions are met:

  1. The resident has active infection with highly transmissible or epidemiologically significant pathogens that have been acquired by physical contact or airborne or droplet transmission.
  2. Precautions are over and above standard precautions. That is, transmission-based precautions (contact, droplet, and/or airborne) must be in effect.
  3. The resident is in a room alone because of active infection and cannot have a roommate. This means that the resident must be in the room alone and not cohorted with a roommate regardless of whether the roommate has a similar active infection that requires isolation.
  4. The resident must remain in his/her room. This requires that all services be brought to the resident (e.g. rehabilitation, activities, dining, etc.).

In a recent email received from CMS the Agency indicates that providers should continue to code residents for the O0100M isolation item per current MDS-RAI manual instructions.

AHCA recognizes that many providers have applied recent CMS and CDC guidance and 1135 waivers during the COVID-19 emergency and have sometimes cohorted beneficiaries in the same isolation room when the residents have tested positive for COVID-19 or are presumed to be positive. We also recognize that with respect to payment models including PDPM, State case-mix, and Medicare Advantage, the current inability to code for isolation in situations where residents were required to be cohorted into the same room may result in a lower payment rate. CMS is aware of this concern. AHCA will share updates as they become available.

CMS Updates PDPM ICD-10 Mappings for New COVID-19 Diagnosis Code

CMS has responded to member concerns that the ICD-10-CM diagnosis codes identified by the CDC as appropriate to code for COVID-19 were not compatible with the Medicare Part A SNF PPS PDPM payment model. Specifically, none of the CDC identified codes could be used to represent the Primary Reason for SNF Stay on the MDS assessment Item I0020B.

On March 31, CMS posted an updated FY 2020 PDPM ICD-10 Mappings file (.zip) which adds the ICD-10-CMS code ‘U07.1 – 2019-nCoV acute respiratory disease’ as an appropriate code to enter in the MDS I0020B Primary reason for SNF stay item field. If entered, this code will map to the PDPM ‘Pulmonary’ default clinical category used for the PT, OT, and SLP components. This new code does not impact the PDPM Nursing or NTA component classifications at present.

This new code U07.1 is ONLY in effect for assessments with target date April 1, 2020 and later. For assessments with an assessment reference date March 31, 2019 or earlier, providers will need to enter the most appropriate ICD-10 code available that is not listed as a ‘return to provider’ code in the MDS I0020B item field.

Additional files related to coding specifications necessary for software companies to implement this change are located on the MDS 3.0 Technical Information webpageProviders do not need to review these files but should check with their MDS software vendors to confirm when these updated have been applied or you will see a ‘return to provider’ error in your MDS software.

CMS Suspends Most Medicare Fee-For-Service Medical Review

CMS released a COVID-19 Provider Burden Relief FAQ document that states that the Agency has suspended most Medicare Part A and Part B Fee-For-Service (FFS) medical review during the emergency period due to the COVID-19 pandemic.  This includes pre-payment medical reviews conducted by Medicare Administrative Contractors (MACs) under the Targeted Probe and Educate program, and post-payment reviews conducted by the MACs, Supplemental Medical Review Contractor (SMRC) reviews and Recovery Audit Contractor (RAC). No additional documentation requests will be issued for the duration of the PHE for the COVID-19 pandemic. Targeted Probe and Educate reviews that are in process will be suspended and claims will be released and paid. Current postpayment MAC, SMRC, and RAC reviews will be suspended and released from review.

This suspension of medical review activities is for the duration of the PHE. However, CMS may conduct medical reviews during or after the PHE if there is an indication of potential fraud. Other topics in the FAQ are related to proof of delivery beneficiary signature waivers for drugs and DME, and for pausing non-emergent ambulance and home health review choice demonstrations Providers should contact their Medicare review contractor if there are questions.

Please email for additional questions, or visit for more information.This message contains confidential information and is intended only for AHCA/NCAL membership. Dissemination, distribution or copying the contents of this email beyond this group is strictly prohibited.