Payer Bill Split Requirement: Separate Claims to Avoid Edit


Pay attention to the 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 better capture the disease process of COVID-19. These codes were first introduced at the Coordination and Maintenance Committee meeting on September 8, 2020 and have since been approved and made available on January 1, 2021 for reporting purposes.

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

Payors require a claim to be split by year when the claim covers both calendar years 2020 and 2021, with respect to Z20.822 and Z20.828. Although this is not official payment guidance, providers are finding that this is the case for the majority of payers. For example, if a patient underwent preoperative testing, including COVID screening (Z20.828), in December 2020, with an outpatient surgery date of January 2021, the claim will likely be paid split by year. Please refer to the example specific claim below:

  • A patient undergoes preoperative testing, including COVID screening (Z20.828), December 31, 2020.
  • The patient is operated on as an outpatient on January 5, 2021.
  • The claim dates are 12/31/20 to 01/05/21 (which includes preoperative testing and outpatient procedure on claim).
  • The coder correctly assigns Z20.828, based on the 2020 COVID preoperative screening service date.
  • Code Z20.828 is amended as an invalid code on this claim with a release date of 2021 due to COVID test DOS: December 31, 2020.
  • With a 2020 COVID test date, you must split the 2020 fee with Z20.828 and submit a separate request for the specific 2021 fee to avoid the change.

The new ICD-10-CM codes implemented on January 1, 2021 include the following:

    1. J12.82 – Pneumonia due to coronavirus disease 2019
    2. M35.81 – Multisystem inflammatory syndrome
    3. Z11.52 – Meeting for COVID-19 screening (note: this code is only to be used after the end of the health emergency)
    4. Z20.822 – Contact and (suspected) exposure to COVID-19
    5. M35.89 – Other specified systemic connective tissue disorder
    6. Z86.16 – Personal history of COVID-19

This unprecedented period of coding updates highlights the critical importance of ensuring quality and consistent medical coding training for your team. Additionally, given the expanded documentation, coding, and reporting of COVID-19 encounters, providers will need to demonstrate efforts to comply with published guidance. The engagement of a Clinical Documentation Integrity (CDI) team has proven to be beneficial in helping facilities conduct concurrent and retroactive assessments of documentation and coding of COVID-19 encounters. These efforts could go a long way in demonstrating compliance of practices and potentially avoiding recoveries from payer audits.

There were 27 new ICD-10 codes for COVID-19-related conditions, monoclonal antibodies, and more, which went into effect on January 1, 2021. The impact COVID-19 has had on medical coding and the billing is simply outstanding. It was undoubtedly a year filled with challenges; however, in addressing these challenges, the industry has uncovered opportunities for long-term efficiencies and improvements that will extend far beyond the pandemic.

Note on programming: Hear Susan Gatehouse report this story live today during Talk Ten on Tuesdays at 10 a.m. EST.

The January 2021 ICD-10-CM Addenda and updated official ICD-10-CM guidance for coding and reporting are available on the CDC website:

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

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