Ensuring Compliant CDI Query Scenarios for COVID-19

Obtaining clinical documentation that captures the patient's severity of illness (SOI) and risk of mortality (ROM) should be the objective of every clinical documentation integrity (CDI) program as providers continue to treat COVID-19 patients. Furthermore, identifying and clarifying missing, conflicting, or nonspecific physician documentation related to diagnoses and procedures is essential to improve documentation to reflect quality and outcome scores. While accurate reimbursement is usually a key goal of a CDI program, it shouldn't be the only goal, and the CDI staff should not lead the medical staff to think of it as the primary reason for the program.

The COVID-19 public health emergency (PHE) is putting incalculable stress on individuals, families, the economy, and addressing this global pandemic requires unprecedented action by everyone. Because of the declared PHE, the World Health Organization (WHO) created an emergency ICD-10 code to identify this new coronavirus. Code U07.1 became effective on April 1, 2020. When COVID-19 meets the definition of principal diagnosis, code U07.1 should be sequenced first, followed by the appropriate codes for the associated manifestation. The sequencing of the principal diagnosis is dependent on the circumstances of admission and must be decided on a case-by-case basis.

Code U07.1 was added to three different Major Diagnostic Categories (MDCs), and the most common resulting MS-DRGs (177, 178 and 179) will be assigned to MDC 4, the respiratory MDC. Complex pneumonias are located in these MS-DRGs.

From an APR DRG standpoint, COVID-19 is also added to three Major Diagnostic Categories (MDCs), with the most commonly assigned APR DRG being 137. It will be important to emphasize that COVID-19 will default to the SOI level three and the ROM level two.

For cases where there is a concern about a possible exposure to COVID-19, but this is ruled out after evaluation, assign code Z03.818, Encounter for observation for suspected exposure to other biological agents ruled out (CDC, 2020).

For cases where there is an actual exposure to someone who is confirmed or suspected (not ruled out) to have COVID-19, and the exposed individual either tests negative or the test results are unknown, assign code Z20.828, Contact with and (suspected) exposure to other viral communicable diseases.¹

If an asymptomatic patient with no known exposure is screened for COVID-19, it is classified to code Z11.59. This code can only be used with negative or unknown test results. Furthermore, if an asymptomatic individual is screened for COVID-19 and tests positive, then you would assign code U07.1 and show the positive COVID-19 result.

The record review process should include addressing all components of the patient record as possible sources for query opportunities. Every documentation deficiency presents a potential opportunity for a physician query. CDI professionals have identified the need for the following query templates when reviewing COVID-19 health records to establish COVID-19 relationship with other conditions and to validate the diagnosis of COVID-19. There are currently two free and downloadable templates (PDF format) developed by and available from AHIMA.

CDI professionals need to make sure to avoid over-reporting COVID-19, and we should be stewards of honest documentation and coding, making sure we issue a query anytime clinical indicators are necessitating it. CDI professionals are encouraged to use these existing templates to avoid leading queries and making sure the query format is as compliant as possible.

If the provider is documenting the patient has presumed COVID-19, then a query may be necessary to clarify what the provider intended to mean by documenting presumed. A query might be necessary to see if the provider is ruling in the diagnosis or ruling it out. If presumed means the provider is confirming COVID-19, despite not testing, then assign code U07.1 for the confirmed case of COVID-19.

If the provider has documented COVID-19 as a definitive diagnosis prior to test results and the test results come back negative, it would be appropriate to query the provider for the confirmation of the final diagnosis. The provider should be given the opportunity to reconsider the diagnosis based on the new information. Ultimately, it is up to the provider to determine the diagnosis. One example would be if the provider feels, based on other factors present, that the test came back as a false negative. If the provider documents COVID-19, even though the test results are negative, code U07.1 would be assigned.

If a patient is readmitted shortly after treatment for COVID-19 for an entirely different reason and the current status of the COVID-19 is not clear, then the provider needs to be queried for clarification. If the patient no longer has COVID-19, then assign code Z86.19, which is a personal history of other infectious and parasitic diseases as a secondary diagnosis.

The courage and dedication of our front-line health care workers who show up every day to care for their communities are an inspiration to us all, and CDI professionals owe them the same kind of dedication by easing administrative burden and providing clear guidelines for the critical data needed to care for and treat COVID-19 patients.

Alba Kuqi (albakuqi88@gmail.com) is an ACDIS Leadership Council member, PHIMA member, American Urological Association member, and an AHIMA Foundation Research Network Volunteer. 

Notes:

1. The Centers for Disease Control and Prevention. ICD-10-CM Coding and Reporting Guidelines April 1, 2020 Through September 30, 2020. https://www.cdc.gov/nchs/data/icd/COVID-19-guidelines-final.pdf?fbclid=IwAR06h6zP8KkehNzjEqlpGvACzMBhP26Khp9WG1JqbfLUQpYOt_LCqwGVHxU

References

American Health Information Management Association. COVID-19 CDI Query Template. https://www.ahima.org/landing-pages/covid-19-cdi-query-templates-landing-page/

American Health Insurance Providers. Health Insurance Providers Respond to Coronavirus (COVID-19), September 22, 2020 https://www.ahip.org/health-insurance-providers-respond-to-coronavirus-covid-19/