Coding Tip: Covid-19 Diagnosis Coding Common Scenarios

Pat Maccariella‑Hafey
RHIA, CDIP, CCS, CCS‑P, CIRCC
Executive Director Of Education
AHIMA‑Approved ICD‑10‑CM/PCS Trainer and Ambassador

Updated 1/19/21. Original post here. 

With the proliferation of COVID-19 cases, we thought we would put together a quick reference listing of some of the common scenarios that coders have asked about. As with all coding, coders should follow Official Guidelines for Coding and Reporting and the COVID-19 Frequently Asked Questions document by the AHA. The links are in the references. The scenarios below are for coding cases as of April 1, 2020 and for the most part applicable for all sites of encounter:

A patient presents for respiratory symptoms of COVID-19 such as SOB, is tested, and tests positive for COVID-19. How is this coded?

Assign code U07.1, Covid-19. Do not assign the symptoms as they are integral to COVID-19

A patient presents for respiratory symptoms of COVID-19.  The patient is tested but the test result is negative for COVID-19. The physician states after seeing the test result and given the patient’s symptoms and clinical picture that he still believes the patient has COVID-19 and is treating the patient as if he does have it. How is this coded?

Assign code U07.1, Covid-19. Do not assign the symptoms as they are integral to COVID-19. Per FAQ even though the test results are negative, or if the provider documented disagreement with the test results, assign code U07.1, Covid-19.  Also code any related diagnoses such as viral pneumonia as secondary diagnosis.

A patient is admitted with symptoms of COVID-19 and sepsis.  The patient test results are positive for COVID-19.  Patient is treated for viral sepsis as well.  Is U07.1, COVID-19 always sequenced as the principal diagnosis?

The principal diagnosis will depend on the circumstances of admission.  Every case can be different so coders must review the clinical presentation of the patient, the documentation and treatment and then make a decision as they would in any case in which they are trying to determine the principal diagnosis. There is no rule that U07.1 must always be principal. We sent this to AHA to confirm, and they stated: “Therefore, if the patient is admitted for sepsis due to COVID-19, sequence code A41.89, Other specified sepsis, for viral sepsis as principal diagnosis. Code U07.1, COVID-19, would be assigned as an additional diagnosis to specify the COVID-19 infection.”

A COVID-19 patient admitted to the hospital with acute hypoxic respiratory failure that progresses to ARDS (acute respiratory distress syndrome).  Can I code both J96.01, acute hypoxic respiratory failure and J80, ARDS to show the severity of illness and risk of mortality of this patient?

No, assign code U07.1, COVID-19 as principal diagnosis with secondary diagnosis of J80, ARDS.   There is an excludes1 note at J96 that excludes J80. HIA also recently wrote a letter to AHA asking this question and they stated to code J80 only as the ARDS is a life-threatening form of respiratory failure and is not an unrelated condition..  Code J80 would capture both.

When acute hypoxic respiratory failure present on admission progresses to ARDS after admission, would the POA of the J80, ARDs be Yes or No?

We would assign a POA of Yes for J80 because ARDS is a life-threatening form of respiratory failure and is not an unrelated condition.  There are Coding Clinics regarding similar situations and AHA states that progressions of a disease process would be considered present on admission if a different code it assigned.  See AHA Coding Clinic for ICD-10-CM/PCS, First Quarter 2020: Page 4; Coding Clinic for ICD-10-CM/PCS, Third Quarter 2019: Page 12.

A patient comes in with SOB and chest pain suspicious for COVID-19. COVID-19 test is negative.  MD does not document COVID-19 or presumed COVID-19. What is assigned?

Assign the symptoms or assign the condition found to be responsible for the symptoms as the principal diagnosis or primary diagnosis for the encounter.  Assign Z20.828, Contact with and (suspected) exposure to other viral communicable diseases as a secondary diagnosis (Z20.822 Contact with and (suspected) exposure to COVID-19  after 1/1/2021). This will show that the patient was tested after suspicion for COVID-19 symptoms, but the result was negative, and that the MD did not think the patient had COVID-19.

A patient is coming to get testing after being exposed to a COVID-19 patient. They want to know if they are positive. The patient has no signs or symptoms. The test is negative.  What is assigned? What about if the test result is not known?

Per June 4, 2020 AHA FAQ, assign Z03.818, Encounter for observation for suspected exposure to other biological agents ruled out.  This code is assigned because in this instance, the patient was exposed to a COVID-19 patient but has no symptoms whatsoever and the test result was negative.  Hospitals and other facilities may want to wait for the test results before coding the claim.  Always check with your facility to see if they are holding claims until final testing result is available.

*In early July, CDC released the FY2021 ICD-10-CM Official Guidelines for Coding and Reporting effective October 1, 2020. In the below you will see that the advice has changed from what was provided in the AHA FAQ document. Please see (f) Screening for COVID-19 below. The advice states that now for screening for COVID-19 and negative test result, regardless of symptoms, should be coded Z20.828 and not Z11.59 or Z03.818 as these are considered screening codes. The reason is that we are in a COVID-19 pandemic and the screening codes would no longer apply. Some facilities have decided to implement the below advice now. HIA had sent a letter to AHA regarding this information in June, that was also sent to the EAB and we are still awaiting reply.

ICD-10-CM Official Guidelines for Coding and Reporting FY 2021 Page 31 of 126

(e) Exposure to COVID-19
For asymptomatic individuals with actual or suspected exposure to COVID-19, assign code Z20.828, Contact with and (suspected) exposure to other viral communicable diseases. For symptomatic individuals with actual or suspected exposure to COVID-19 and the infection has been ruled out, or test results are inconclusive or unknown, assign code Z20.828, Contact with and (suspected) exposure to other viral communicable diseases. See guideline I.C.21.c.1, Contact/Exposure, for additional guidance regarding the use of category Z20 codes. If COVID-19 is confirmed, see guideline I.C.1.g.1.a

(f) Screening for COVID-19
During the COVID-19 pandemic, a screening code is generally not appropriate. For encounters for COVID-19 testing, including preoperative testing, code as exposure to COVID-19 (guidelineI.C.1.g.1.e). Coding guidance will be updated as new information concerning any changes in the pandemic status becomes available.

A patient with exposure to a COVID-19 patient without symptoms presents for testing.  The COVID-19 test is positive. There is no contrary information from the physician.  Must the patient have symptoms to code U07.1 or can U07.1 be assigned when only a positive test result is found?

Assign U07.1, COVID-19 for a patient who’s test results are positive for COVID-19. The patient does not have to have symptoms to code U07.1. Hospitals may want to query the physician if there is any doubt that the patient has current COVID-19.  This is becoming an issue because some patients are testing positive when they are actually just shedding the virus and the test comes out positive.  Hopefully AHA will address this issue in future FAQs.

We now have patients coming in strictly for antibody testing outpatient.   They simply want to know if they had COVID-19 in the past and did not know it.  How would this be coded?

Assign Z01.84, Encounter for antibody response examination for the diagnosis.

We have a patient without symptoms, without exposures to COVID-19 who is very fearful that she has COVID-19. There are no symptoms, signs or anything else found by the physician.  The patient does not qualify for testing for COVID-19 per the CDC.  How should we code this encounter?

The best code for this situation is Z71.1, Patient with feared complaint in whom no diagnosis is made. See AHA Coding Clinic, Fourth Quarter 2016: Page 4 for a similar situation in which Z71.1 was assigned.

How should we code neonates/newborns that test positive for COVID-19? (5/26/2020)

When coding the birth episode in a newborn record, the appropriate code from category Z38, Liveborn infants according to place of birth and type of delivery, should be assigned as the principal diagnosis. For a newborn that tests positive for COVID-19, assign code U07.1, COVID-19, and the appropriate codes for associated manifestation(s) in neonates/newborns in the absence of documentation indicating a specific type of transmission. For a newborn that tests positive for COVID-19 and the provider documents the condition was contracted in utero or during the birth process, assign codes P35.8, Other congenital viral diseases, and U07.1, COVID19.

A patient was treated for pneumonia and pneumothorax due to COVID-19 and discharged from the hospital. Later the same day, the patient presented to the emergency department with pneumothorax and was readmitted due to increasing shortness of breath and for pneumothorax evacuation. Chest tube was inserted, the patient improved and was discharged. How should the readmission be coded? (7/22/2020)

Assign code U07.1, COVID-19, as the principal diagnosis, and code J93.83, Other pneumothorax, as a secondary diagnosis. Since the pneumothorax due to COVID-19 present on the first admission has not resolved, this appears to be ongoing treatment for a COVID-19 manifestation. If the documentation is not clear regarding whether the physician considers a condition to be an acute manifestation of a current COVID-19 infection vs. a residual effect from a previous COVID-19 infection, query the provider. As stated in the Official Guidelines for Coding and Reporting, the provider’s documentation that the individual has COVID-19 is sufficient for coding purposes.

A patient was hospitalized a few weeks ago for pneumonia due to COVID19. The patient now presents to the emergency department with shortness of breath and is admitted. The discharge diagnosis for this admission is “pneumothorax due to a previous history of COVID-19.” How should this admission be coded? (7/22/2020)

Assign code J93.83, Other pneumothorax, as the principal diagnosis, followed by code B94.8, Sequelae of other specified infectious and parasitic diseases. In this case, the patient no longer has COVID-19 and the pneumothorax is a residual effect (sequelae). A personal history code is not appropriate because as stated in guideline I.C.21.c.4), “Personal history codes explain a patient’s past medical condition that no longer exists and is not receiving any treatment, but that has the potential for recurrence, and therefore may require continued monitoring.” The patient is clearly receiving treatment for the residual effect of COVID-19.

A patient was diagnosed with COVID-19 infection a week ago and is admitted after developing acute onset shortness of breath associated with upper back pain as well as dizziness without syncope. The patient continued to experience symptoms of COVID-19 infection. Patient was discharged with the diagnosis of pulmonary embolism (PE) and COVID-19. What are the appropriate codes? (7/22/2020)

Assign code U07.1, COVID-19, as the principal diagnosis, followed by code I26.99, Other pulmonary embolism without acute cor pulmonale, for a patient diagnosed with pulmonary embolism and COVID-19. The pulmonary embolism is a manifestation of the COVID-19 infection. Per the instructional note under code U07.1, COVID-19 should be sequenced as the principal diagnosis and additional codes should be assigned for the manifestations.

A patient is readmitted due to shortness of breath following a previous admission for COVID-19 and associated respiratory failure. The patient no longer has COVID-19. The final diagnosis is “pulmonary embolism due to previous COVID-19.” What are the appropriate codes? (7/22/2020)

Assign code I26.99, Other pulmonary embolism without acute cor pulmonale, as the principal diagnosis, followed by code B94.8, Sequelae of other specified infectious and parasitic diseases, as a secondary diagnosis.

A nursing home patient was hospitalized for COVID-19 and pneumonia. He has completed treatment, but he cannot go back to the nursing home until he tests negative for COVID-19, so he is admitted to the skilled nursing facility (SNF) unit at the hospital until he tests negative and can return to the nursing home where he resides. What code should be assigned for the hospital SNF unit stay? (7/22/2020)

Assign code U07.1, COVID-19, as the patient still has COVID-19. Do not assign a code for the pneumonia as the condition has resolved.

A patient was diagnosed with “Guillian-Barre Syndrome which is likely a parainfectious complication of recent COVID-19 infection.” The patient no longer has COVID-19. How should this be coded? (7/22/2020)

Assign code G61.0, Guillain-Barre syndrome, as the principal diagnosis, followed by code B94.8, Sequelae of other specified infectious and parasitic diseases.

A patient was transferred from a short term acute care hospital to a long term acute care hospital (LTCH) for continued treatment of acute hypoxic respiratory failure due to COVID-19. What are the appropriate codes for the LTCH admission? (7/22/2020)

Assign code U07.1, COVID-19, as the principal diagnosis, and code J96.01 Acute respiratory failure with hypoxia, as a secondary diagnosis. Per the instructional note under code U07.1, COVID-19 should be sequenced as the principal diagnosis and additional codes should be assigned for the manifestations.

A patient was transferred from an acute care hospital to a rehab facility due to sequelae of a COVID-19 infection, including critical illness myopathy and peroneal palsy in the right lower extremity. The patient no longer has COVID-19. What codes should be assigned? (7/22/2020)

Assign codes G72.81, Critical illness myopathy, and G57.31, Lesion of lateral popliteal nerve, right lower limb. Assign code B94.8, Sequelae of other specified infectious and parasitic diseases, as a secondary diagnosis for the sequelae of a COVID-19 infection.

A patient was transferred from an acute care hospital to a rehab facility for deconditioning for generalized debility due to prolonged hospitalization for COVID-19 which has now resolved. What codes should be assigned? (7/22/2020)

Assign codes for the specific symptoms (such as generalized weakness, debility, etc). Assign code Z86.19, Personal history of other infectious and parasitic diseases, as a secondary diagnosis (Z86.16, Personal history of COVID-19 as of 1/1/21). Do not assign code B94.8, Sequelae of other specified infectious and parasitic diseases, as the debility is due to the prolonged hospitalization rather than being a sequela of the COVID-19 infection.

What is the ICD-10-CM diagnosis code(s) for a child admitted due to documented multisystem inflammatory syndrome in children (MIS-C) due to COVID-19? (7/23/2020)

Assign code U07.1, COVID-19, as the principal diagnosis, and code M35.8, Other specified systemic involvement of connective tissue, as a secondary diagnosis (M35.81, Multisystem inflammatory syndrome after 1/1/21), for MIS-C due to COVID-19. The MIS-C is a manifestation of the COVID19 infection. Per the instructional note under code U07.1, COVID-19 should be sequenced as the principal diagnosis and additional codes should be assigned for the manifestations.
If the documentation is not clear regarding whether the physician considers a condition to be an acute manifestation of a current COVID-19 infection vs. a residual effect from a previous COVID-19 infection, query the provider. As stated in the Official Guidelines for Coding and Reporting, the provider’s documentation that the individual has COVID-19 is sufficient for coding purposes.

A child diagnosed with COVID-19 several weeks ago is now admitted with multisystem inflammatory syndrome in children (MIS-C) due to COVID-19. The patient no longer has COVID-19. How should this be coded? (7/23/2020)

Assign code M35.8, Other specified systemic involvement of connective tissue, as the principal diagnosis (M35.81, Multisystem inflammatory syndrome after 1/1/21), for the MIS-C, and code B94.8, Sequelae of other specified infectious and parasitic diseases, as a secondary diagnosis for the sequelae of a COVID-19 infection. If the documentation is not clear regarding whether the physician considers a condition to be an acute manifestation of a current COVID-19 infection vs. a residual effect from a previous COVID-19 infection, query the provider. As stated in the Official Guidelines for Coding and Reporting, the provider’s documentation that the individual has COVID-19 is sufficient for coding purposes.

Will new ICD-10-PCS procedure codes be created to identify the use of specific drugs and other therapeutic substances for treatment of COVID-19 in the hospital inpatient setting? (7/30/2020)

In response to the COVID-19 pandemic, the Centers for Medicare and Medicaid Services (CMS) implemented 12 new ICD-10-PCS procedure codes to describe the introduction or infusion of therapeutics for the treatment of COVID-19, effective with discharges on or after August 1, 2020.

The Code Tables, Index and related Addenda files for the 12 new procedure codes are available at: https://www.cms.gov/Medicare/Coding/ICD10/2020-ICD-10-PCS

What ICD-10-PCS procedure codes should be assigned to identify the administration of specific drugs, such as remdesivir, to treat COVID-19 in the hospital inpatient setting? (7/30/2020)

For a full list of COVID-19 Procedures effective 1/1/21 see blog post here:  https://www.hiacode.com/education/covid-19-codes-2021/

Effective with discharges on or after August 1, 2020, new ICD-10-PCS codes have been implemented for the administration of three different drugs when used to treat COVID-19.

• XW033E5, Introduction of Remdesivir Anti-infective into Peripheral Vein, Percutaneous Approach, New Technology Group 5
• XW043E5, Introduction of Remdesivir Anti-infective into Central Vein, Percutaneous Approach, New Technology Group 5
• XW033G5, Introduction of Sarilumab into Peripheral Vein, Percutaneous Approach, New Technology Group 5
• XW043G5, Introduction of Sarilumab into Central Vein, Percutaneous Approach, New Technology Group 5
• XW033H5, Introduction of Tocilizumab into Peripheral Vein, Percutaneous Approach, New Technology Group 5
• XW043H5, Introduction of Tocilizumab into Central Vein, Percutaneous Approach, New Technology Group 5

These codes should only be assigned when these drugs are administered to treat COVID-19.

For more FAQ, visit: https://journal.ahima.org/ahima-and-aha-faq-on-icd-10-cm-coding-for-covid-19/

References
codingclinicadvisor.com/faqs-icd-10-cm-coding-covid-19
cdc.gov/nchs/data/icd/COVID-19-guidelines-final.pdf

The information contained in this post is valid at the time of posting. Viewers are encouraged to research subsequent official guidance in the areas associated with the topic as they can change rapidly.