Guest post: Counting COVID-19 cases

by Howard Rodenberg, MD, MPH, CCDS

I sometimes drift through our office space—often deserted now in the era of COVID-19—and think about how the cubicles represent our spot in the healthcare industry. CDI occupies a single cubicle somewhere on the Revenue Cycle’s floor. It’s our own little niche, a “boutique practice” that nobody outside our club really understands, and where we are hidden far enough from the door that no one else sees us as they walk into the building. To some extent, we should just be grateful that we’re not in the basement looking for our stapler, but every now and then something happens that should make us reconsider our tendency to live within the cubicle walls.

You’ve probably heard the accusation that hospitals are paid more to label patients with COVID-19. They do so strictly for the money, according to the rumors, and that falsely drives up the number of COVID cases. Similarly, doctors are paid to list COVID as the cause of death on legal documents, receiving a bounty payment in return. Because of these financial incentives, hospitalizations and deaths from COVID-19 are inflated, and the pandemic isn’t as bad as it seems.

There is a lot to unpack in these statements, the very least of which is that such statements are baseless accusations against those hospitals and healthcare workers who have placed themselves at risk caring for those the government seems to ignore. But in this case our community has a unique set of knowledge to help us combat misinformation. The need to refute these statements is clearly within the CDI wheelhouse, and it’s here where we need to engage.

Let’s start with the idea that hospitals are paid more if someone is diagnosed with COVID-19. There is a kernel of truth in this. You’ll recall that when the new SARS-CoV-2 coronavirus code (U07.1) was developed, it was quite properly placed within the DRG 177-79 triad for respiratory infections and inflammations. This is the more severe category of pneumonia that generally requires more evaluation, monitoring, and care than those of a “simpler” variety.

In addition, given the increased care needs and prolonged length of stay associated with COVID infection, CMS established an additional 20% payment bonus in those cases where the diagnosis of COVID infection could be definitively established by a positive test. These are all good, proper, and responsible ways for CMS to ensure that hospitals are properly reimbursed in caring for these severely ill patients.

But is there an incentive for a hospital to label a patient with COVID when that’s not the diagnosis in play? The answer is clearly no. First, as we know from our work, one cannot simply code a diagnosis for which there are no supportive clinical indicators. Establishing a diagnosis of COVID follows the same rules as any other “codeable” diagnosis: It must be documented in a consistent fashion by the provider, and must demonstrate an impact upon the course of clinical evaluation, monitoring, treatment, nursing care, or length of stay.

Finally, there’s the risk of being investigated for fraud, especially if your facility seems the have a higher-than expected rate of COVID diagnoses. The audit process will inevitably catch these outliers and penalties will follow. The bottom line is that you can’t just staple “COVID” to a patient’s record because they have the sniffles while getting their hip fixed.

While one might see an iota of reality behind the claim that hospitals get paid more for a patient with COVID, there is no truth whatsoever in the claim that doctors are declaring COVID deaths for money. On a fundamental level, the death certificate asks the physician for the proximate cause of death and for other associated conditions. It’s very analogous to what we do in CDI, noting a principal diagnosis (the proximate cause of death) and the secondary or additional conditions also present at the time of death. So, while a patient may have underlying heart failure and chronic obstructive pulmonary disease which may put him at special risk, COVID infection (if listed as the proximate cause) is what tipped them over the edge. At best, this is a case of confusing causation with association; more likely, it’s a disingenuous act of distorting the facts to suit one’s presumptions.  

Needless to say, there is no incentive whatsoever for a physician to list COVID-19 as the proximate cause of death. No physician receives any incentive money to do so. None. Claiming that doctors cite COVID for money denigrates an entire core of professionals who responded selflessly to the front lines of the pandemic in order to score a sound bite.

(There are a lot more things I would like to say. The accusations of doctors faking COVID deaths for money brings the word “vile” to mind as the politest of the four-letter phrases I might use.)

I truly don’t intend for this call to action to be a political statement. To the extent that these statements are proffered by one party or another, I suppose some will see it that way. But these rumors will persist long after the current election cycle, and to me this is a matter of factual integrity that CDI professionals are in a unique position to address.

When we hear these statements in the community or from friends and family, I believe we have a professional obligation to provide honest, fact-based explanations. It’s up to others to accept them or not; we can’t change that. But to remain silent is to acquiesce to the corruption of our work.

Editor’s note: Rodenberg is the adult physician advisor for CDI at Baptist Health in Jacksonville, Florida. Contact him at howard.rodenberg@bmcjax.com or follow his personal blog at writingwithscissors.blogspot.com. Opinions expressed are that of the author and do not necessarily represent those of ACDIS, HCPro, or any of its subsidiaries.