From 3M Health Information Systems
Coding focus as the pandemic continues
Now that we have seen many cases of COVID-19 being treated and recovered patients moving on with their “new normal” lives (at least in some states), we should take a moment to think about additional coding scenarios we may encounter. We will most likely see a multitude of patients with a history of COVID-19. Examples may include patients being treated in outpatient settings for sequelae from the virus including post-traumatic stress disorder, anxiety and depression, as well as cognitive and physical debility caused by the long duration of the illness. We may see patients that are readmitted after completing treatment for COVID-19. In addition, there may be instances where family history of COVID-19 will come into play. Follow up visits, especially in the outpatient arena, will become common. We would also expect to see patients receiving antibody testing rather than a test to confirm the virus or as a follow up to having the virus. Below are a few examples of what you may encounter.
History of COVID-19 infection
Scenario # 1
A patient presents to the Emergency Room this evening with fever and cough that has last for two days. In the patient’s history, the provider notes that the patient had pneumonia two years ago. He also documents that the patient had previously tested positive for the virus, completed treatment and no longer has COVID-19. After work up, the patient is diagnosed with an upper respiratory infection.
J06.9 – Acute upper respiratory infection, unspecified
Z86.19 – Personal history of other infectious and parasitic diseases
Z87.01 – Personal history of pneumonia (recurrent)
A patient comes in for a primary care visit to be seen for his chronic conditions of hypertension, hyperlipidemia and gastroesophageal reflux disease (GERD). The provider documents that four weeks prior to the encounter the patient had tested positive for COVID-19 and isolated for fourteen days. She also documents that the patient has not received a repeat COVID test. The patient’s chronic conditions are reviewed, and medications of amlodipine, atorvastatin and omeprazole are adjusted appropriately.
I10 – Essential (primary) hypertension
E87.5 – Hyperlipidemia, unspecified
K21.9 – Gastro-esophageal reflux disease without esophagitis
Query – This documentation presents a query opportunity. Per AHA Coding Clinic 2nd Quarter 2020, page 12, to identify COVID-19 in a history status, the provider must document that the patient no longer has the virus. It cannot be based on a timeframe alone. It is unclear if the physician has determined if the infection is still present, especially since the patient has not undergone additional COVID-19 testing. For organizations that currently do not have a query process in place for these outpatient encounters, we recommend that you consider developing this process as part of your CDI program. For help with this, review to the ACDIS/AHIMA’s “Guidelines for Achieving a Compliant Query Process.”
Family history of COVID-19
A nineteen-year-old patient is brought to Urgent Care for a cough, runny nose and sore throat. The provider notes the patient typically has these symptoms in the spring due to allergies. He also notes that the patient attended a wedding with his parents and that his father had been positive for COVID-19 but did receive a negative test two weeks prior to attending the wedding. After workup, the provider reports final diagnoses of acute sinusitis and family history of COVID-19.
J01.90 – Acute sinusitis, unspecified
Z83.1 – Family history of other infectious and parasitic diseases
Follow-up for COVID-19
A patient is discharged from the hospital after a 10- day stay for treatment of COVID-19. Prior to discharge, the patient had a negative COVID test result. On the day of discharge, the patient presents to primary care fora follow-up visit. The provider’s final diagnosis is “follow up COVID-19, virus no longer present”
Z09 – Encounter for follow-up examination after completed treatment for conditions other than malignant neoplasm
Z86.19 – Personal history of other infectious and parasitic diseases
Query– Now, for those of you that chuckled when you saw the final diagnosis as documented in this record, you may have work to do. If your providers do not document in this manner it may benefit you to provide some physician education or you will need to be prepared to query your providers regarding the status of the COVID-19 infection. There are other phrases providers can use, but it must be very clear that the patient no longer has the infection.
COVID-19 antibody testing only
A patient presents to a physician’s office requesting antibody testing to determine if they have the antibody for the COVID-19 virus. The patient has had no symptoms and does not require a COVID-19 test. The specimen was obtained for the antibody testing only and patient will be contacted when results are available.
Z01.84 – Encounter for antibody response examination
And hopefully we will have a COVID-19 vaccine soon and will need to assign:
Z23 – Encounter for immunization
A patient is readmitted after a recent admission for positive COVID-19 treatment. Provider documentation states the patient remains COVID-19 positive and still under treatment for COVID-19 even though the patient is not re-tested during the current admission.
U07.1 – COVID-19
If the patient still has an active COVID-19 infection which is being evaluated, monitored or treated, then code U07.1 is assigned. Review the record to determine the circumstance of the subsequent admission for identification of principal diagnosis. If COVID-19 meets the definition of principal diagnosis, then code U07.1 will be sequenced as principal diagnosis.
Another similar situation is a patient readmitted to the inpatient setting after discharge three days prior, during which time the patient was treated for COVID-19. The provider documents that the patient is readmitted at this time with asthma exacerbation complicated by COVID-19, and states the patient will not be retested for COVID-19.
In this situation a query should be generated requesting the provider clarify if the patient is still being monitored, evaluated or treated for an active COVID-19 infection on this admission.
If the patient no longer has COVID-19, then assign code Z86.19, Personal history of other infectious and parasitic diseases, as a secondary diagnosis with the asthma exacerbation as the principal diagnosis. If the provider confirms the patient still has an active COVID-19 infection, then code U07.1 will be sequenced as the principal diagnosis followed by asthma exacerbation as the secondary diagnosis. Code assignment is based on the provider documentation. Therefore, if the provider confirms the COVID-19 even without retesting, it is appropriate to assign code U07.1.
Stay safe everyone!
Audrey Howard, RHIA, is a senior outsource services consultant with 3M Health Information Systems.
Bobbie Starkey, RHIT, CCS-P, is an outpatient consultant with 3M Health Information Systems.
During a pandemic, healthcare information is gathered, studied, and published rapidly by scientists, epidemiologists and public health experts without the usual processes of review. Our understanding is rapidly evolving and what we understand today will change over time. Definitive studies will be published long after the fact. 3M Inside Angle bloggers share our thoughts and expertise based on currently available information.