By Cheryl Ericson, MS, RN, CCDS, CDIP
It remains to be seen whether the past few months represent the worst of the COVID-19 pandemic for the US, or the beginning of a long fight. Many were caught off guard when the outbreaks first hit US locales hard, and it has created enormous challenges for the healthcare industry. It is essential that we ensure we are better prepared for any additional outbreaks. Because US providers’ experiences with COVID-19 have differed widely across the country, now is a good opportunity to regroup and assess what we think we know about the virus and how it could impact clinical documentation integrity (CDI) and coding professionals in the future.
First, we continue to learn more ways the body is affected by COVID-19. There is not a one-size-fits-all disease pattern; while some have only mild symptoms or are asymptomatic when infected, others experience severe symptoms that affect the gastrointestinal, neurological, and respiratory systems—among others.1 According to the Centers for Disease Control and Prevention (CDC), most people infected by COVID-19 will experience:2
- Fever (83–99 percent)
- Cough (59–82 percent)
- Fatigue (44–70 percent)
- Anorexia (40–84 percent)
- Shortness of breath (31–40 percent)
- Sputum production (28–33 percent)
- Myalgias (11–35 percent)
Initial reports focused on the respiratory symptoms of hospitalized patients, which often culminated in pneumonia, hypoxemic respiratory failure/acute respiratory distress syndrome, sepsis, and septic shock.3
What does this mean for CDI and coding professionals? Most are aware of the implementation of the new code U07.1 to capture COVID-19. However, many are still struggling with sequencing guidance. According to the ICD-10-CM Official Coding and Reporting Guidelines for April 1, 2020 through September 30, 2020, the following guidance should be applied for sequencing of codes regarding coronavirus infections:4
When COVID-19 meets the definition of principal diagnosis, code U07.1, COVID-19, should be sequenced first, followed by the appropriate codes for associated manifestations, except in the case of obstetrics patients as indicated in Section
I.C.15.s. for COVID-19 in pregnancy, childbirth, and the puerperium.
For a COVID-19 infection that progresses to sepsis, see Section I.C.1.d. Sepsis, Severe Sepsis, and Septic Shock
See Section I.C.15.s. for COVID-19 in pregnancy, childbirth, and the puerperium
This guidance is reinforced by the associated Addenda for the 2020 ICD-10-CM Tabular List of Disease and Injuries, which includes the new code U07.1 for COVID-19 and specifies to use additional code to identify pneumonia or other manifestations.
Further guidance can be found in the recently published “AHIMA/AHA FAQ: ICD-10-CM Coding For COVID-19,” available online at journal.ahima.org. This FAQ addressed the following question, among others:5
Question: Is the new ICD-10-CM code U07.1, COVID-19, a secondary code? (rev. 4/1/2020)
Answer: When COVID-19 meets the definition of principal or first-listed diagnosis, code U07.1, COVID-19, should be sequenced first, and followed by the appropriate codes for associated manifestations, except in the case of obstetrics patients. However, if COVID-19 does not meet the definition of principal or first-listed diagnosis (e.g. when it develops after admission), then code U07.1 should be used as a secondary diagnosis.
COVID-19 as a principal diagnosis typically maps to MS-DRGs 177, 178, or 179, Respiratory Infections and Inflammations, depending on the presence of secondary diagnoses classified as a complication or comorbidity (CC) or major complication or comorbidity (MCC).
The CDC warns that clinicians should be prepared for the condition of patients hospitalized with COVID-19 to deteriorate, as a range of 26 percent to 32 percent of patients were admitted to the intensive care unit (ICU) among all hospitalized patients.6 CDI and coding efforts seek to capture that severity through COVID-19’s manifestations. Most CDI professionals are very familiar with the diagnoses of pneumonia and acute respiratory failure; however, ARDS is a less common diagnosis and is not synonymous with acute respiratory failure within the ICD-10-CM code set. If fact, there is an Excludes1 Note for J96, Respiratory failure, not elsewhere classified that prevents the coding of both a J96- respiratory failure code and ARDS (J80). However, both categories of codes are classified as MCCs when classified as secondary diagnoses.
Acute respiratory failure can be further specified as hypoxic or hypercapnic within ICD-10-CM and is defined by impairment of the respiratory system to maintain normal oxygen and carbon dioxide (CO2) levels when breathing room air. The National Heart, Lung, and Blood Institute defines ARDS as an increase in fluid within the alveolar (air sacs) of the lungs in conjunction with the breakdown of surfactant, a foamy substance that keeps the lungs fully expanded to support breathing.7 ARDS prevents the lungs from properly filling with air, leading to hypoxia as less oxygen enters the blood stream and resulting in clinical and radiographic manifestations of acute pulmonary inflammatory status.8 The CDC found that, among all COVID-19 patients, a range of 3 percent to 17 percent developed ARDS compared to a range of 20 percent to 42 percent for hospitalized patients and 67 percent to 85 percent for patients admitted to the ICU.9 ARDS can lead to permanent damage if the lung tissue scars, leading to stiffness of the lungs.10
Based on the above coding guidelines and tabular list, as well as additional guidelines under acute respiratory illness due to COVID-19, a patient with COVID-19 who develops ARDS would result in a principal diagnosis of U07.1 with ARDS as a manifestation or secondary diagnosis that results in MS-DRG 177. The same MS-DRG would result if the patient was diagnosed with acute hypoxic respiratory failure.
It is important to note that although the guidelines use the phrase “due to COVID-19,” the provider is not required to link respiratory or other manifestations directly to COVID-19. It is sufficient for the patient to be diagnosed with COVID-19 and for there to be documentation of acute respiratory or other conditions in the setting of COVID-19. In fact, this topic is addressed in the recently published “AHIMA/AHA FAQ: ICD-10-CM Coding For COVID-19.”11
Question: Based on the recently released guidelines for COVID-19 infections, does a provider need to explicitly link the results of the COVID-19 test to the respiratory condition as the cause of the respiratory illness to code it as a confirmed diagnosis of COVID-19? Patients are being seeing in our emergency department and if results are not available at the time of discharge, we are reluctant to query the physicians to go back and document the linkage when the results come back several days later. (rev. 4/1/2020)
Answer: No, the provider does not need to explicitly link the test result to the respiratory condition, the positive test results can be coded as confirmed COVID-19 cases as long as the test result itself is part of the medical record. As stated in the coding guidelines for COVID-19 infections that went into effect on April 1, code U07.1 may be assigned based on results of a positive test as well as when COVID- 19 is documented by the provider. Please note that this advice is limited to cases related to COVID-19 and not the coding of other laboratory tests. Due to the heightened need to uniquely identify COVID-19 patients, we recommend that providers consider developing facility-specific coding guidelines to hold back coding of inpatient admissions and outpatient encounters until the test results for COVID-19 testing are available.
In the early stages of the COVID-19 pandemic, most hospitalized patients with respiratory symptoms were placed on a mechanical ventilator as supportive therapy.
Although mechanical ventilation is not a surgical procedure, it can move a medical MS-DRG within the respiratory major diagnostic category, resulting in MS-DRG 207 (Respiratory system diagnosis with vent > 96 hours) or MS-DRG 208 (Respiratory system diagnosis with vent £ 96 hours) depending on the duration of ventilation, which is usually more than 96 consecutive hours.
As mentioned earlier, the CDC also found many COVID-19 patients develop sepsis and septic shock. If the patient is not admitted with sepsis or septic shock, the CDI or coding professional should query the provider to establish whether sepsis was present on admission, as it affects sequencing and the resultant MS-DRG.
The relationship between COVID-19 and sepsis may be a little less obvious than other infection processes, as some patients have mild symptoms for about a week before their condition rapidly deteriorates.12,13
The Global Sepsis Alliance found that “COVID-19 does indeed cause sepsis” and that “virtually all other organ systems can be affected,” supporting severe sepsis or septic shock.14 The most common types of organ failure accompanying sepsis are critical illness polyneuropathy/myopathy, liver injury, and acute kidney failure as well as “septic shock severe enough to require drugs to support the heart and circulation in almost 70% of patients.”15,16
CDI and coding professionals should be looking for evidence of severe sepsis and septic shock in hospitalized COVID-19 patients, who are also likely to be diagnosed with pneumonia and acute respiratory failure or ARDS and may be on a mechanical ventilator—increasing their severity of illness and risk of mortality, especially in the setting of underlying chronic illness. In most cases, especially when sepsis is present on admission, sepsis will be the principal diagnosis.17 COVID-19 is classified as a MCC when sequenced as a secondary diagnosis leading to MS-DRG 870 (Septicemia or severe sepsis with mechanical ventilation > 96 hours, when applicable) or MS-DRG 871 (Septicemia or severe sepsis without MV > 96 hours with MCC).
As more cases of COVID-19 are diagnosed in the US, there is also evidence that COVID-19 can manifest as neurological symptoms that range from loss of smell and inability to taste to seizures, delirium, metabolic encephalopathy, and stroke.18 The CDC reports thromboembolism secondary to COVID-19 infection, which appears to be manifesting as a greater-than-expected number of younger patients without traditional risk factors being hospitalized for, and sometimes dying from, serious strokes.19,20 More research is needed to understand the relationship between COVID-19 and thromboembolism, but CDI and coding professionals need to be aware of this relationship so they are checking the results of COVID-19 testing in these types of patients to ensure proper sequencing of U07.1 as the principal diagnosis followed by a secondary diagnosis of stroke, adding a MCC.
As discussed, COVID-19 can lead to a variety of health issues and it is an important diagnosis to capture. Unlike most other diagnoses, the ICD-10-CM Official Coding and Reporting Guidelines only allows for the reporting of confirmed cases.21,22 But what makes reporting COVID-19 tricky is the prevalence of inaccurate test results, which in turn leads to an inability to “confirm” the diagnosis of COVID-19. According to the Wall Street Journal, health experts believe nearly one in three patients who are infected with COVID-19 are getting a negative test result.23 The “AHIMA/AHA FAQ: ICD-10-CM Coding For COVID-19” clarifies: “The intent of the guideline is to code only confirmed cases of COVID-19. It is not required that a copy of the confirmatory test be available in the record or documentation of the test result. The provider’s diagnostic statement that the patient has the condition would suffice.”5 This is important guidance because the ICD-10-CM Official Coding and Reporting Guidelines also specifically state: “If the provider documents ‘suspected,’ ‘possible,’ ‘probable,’ or ‘inconclusive’ COVID-19, do not assign code U07.1.”24
CDI and coding professionals should recognize that this guideline is similar to what we currently practice in regard to HIV. Likely the best way to address this conundrum is to leverage the guidance regarding “presumptive positive COVID-19 test results should be coded as confirmed.”25 The ICD-10-CM Official Coding and Reporting Guidelines document continues by defining a presumptive positive test as one that has yet to be confirmed by the CDC, but has tested positive elsewhere; however, in light of the frequency of false negative COVID-19 results, one could argue that providers need the ability to make a clinical diagnosis of COVID-19 as they are able to do with HIV disease based on the patient’s symptomology and manifestations. In other words, CDI and coding professionals should educate their providers to document “presumptive COVID-19 with a suspected false-negative result” or “evidence of COVID-19” as a prior publication of the AHA’s Coding Clinic determined “evidence of” a diagnosis “is not considered an uncertain diagnosis and should be appropriately coded and reported.”26
Learning how to accurately report COVID-19 and its manifestation has been a whirlwind process and we will continue to refine our CDI and coding practices as healthcare professionals better understand this virus and its impact on the human body. For now, be sure you understand how to apply current coding guidance and how the infection can manifest so we can obtain accurate data to allow a better understanding of COVID-19.
1. Harvard Health Publishing. “COVID-19 basics.” Updated May 20, 2020. https://www.health.harvard.edu/diseases-and-conditions/covid-19-basics.
2. Centers for Disease Control and Prevention. “Interim Clinical Guidance for Management of Patients with Confirmed Coronavirus Disease (COVID-19).” Updated May 20, 2020. https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-guidance-management-patients.html.
4. Centers for Disease Control and Prevention. “ICD-10-CM Official Coding and Reporting Guidelines April 1, 2020 through September 30, 2020.” https://www.cdc.gov/nchs/data/icd/COVID-19-guidelines-final.pdf.
5. “[Updated April 28] AHIMA and AHA FAQ: ICD-10-CM Coding for COVID-19.” Journal of AHIMA. March 20, 2020. https://journal.ahima.org/ahima-and-aha-faq-on-icd-10-cm-coding-for-covid-19/.
6. Centers for Disease Control and Prevention. “Interim Clinical Guidance for Management of Patients with Confirmed Coronavirus Disease (COVID-19).”
7. National Heart, Lung, and Blood Institute. “Acute Respiratory Distress Syndrome.” Updated September 17, 2019. https://www.nhlbi.nih.gov/health-topics/acute-respiratory-distress-syndrome.
8. Gattinon, Luciano and Eleonora Carlesso. “Acute respiratory failure and acute respiratory distress syndrome.” The ESC Textbook of Intensive and Acute Cardiovascular Care (2 ed.). Oxford University Press, 2018. https://oxfordmedicine.com/view/10.1093/med/9780199687039.001.0001/med-9780199687039-chapter-64.
9. Centers for Disease Control and Prevention. “Interim Clinical Guidance for Management of Patients with Confirmed Coronavirus Disease (COVID-19).”
10. National Heart, Lung, and Blood Institute. “Acute Respiratory Distress Syndrome.”
11. “[Updated April 28] AHIMA and AHA FAQ: ICD-10-CM Coding for COVID-19.”
12. Harvard Health Publishing. “COVID-19 basics.”
13. Centers for Disease Control and Prevention. “Interim Clinical Guidance for Management of Patients with Confirmed Coronavirus Disease (COVID-19).”
14. Zick, Marvin. “Update: Can COVID-19 Cause Sepsis? Explaining the Relationship Between the Coronavirus Disease and Sepsis.” Global Sepsis Alliance. April 7, 2020. https://www.global-sepsis-alliance.org/news/2020/4/7/update-can-covid-19-cause-sepsis-explaining-the-relationship-between-the-coronavirus-disease-and-sepsis-cvd-novel-coronavirus.
15. Centers for Disease Control and Prevention. “Interim Clinical Guidance for Management of Patients with Confirmed Coronavirus Disease (COVID-19).”
16. Zick, Marvin. “Update: Can COVID-19 Cause Sepsis? Explaining the Relationship Between the Coronavirus Disease and Sepsis.”
17. “[Updated April 28] AHIMA and AHA FAQ: ICD-10-CM Coding for COVID-19.”
18. Harvard Health Publishing. “COVID-19 basics.”
20. Centers for Disease Control and Prevention. “Interim Clinical Guidance for Management of Patients with Confirmed Coronavirus Disease (COVID-19).”
21. Centers for Disease Control and Prevention. “ICD-10-CM Official Coding and Reporting Guidelines April 1, 2020 through September 30, 2020.”
22. “[Updated April 28] AHIMA and AHA FAQ: ICD-10-CM Coding for COVID-19.”
23. Burton, Thomas M. “What We Know About Coronavirus Tests, Treatment and Vaccines.” The Wall Street Journal. Updated May 21, 2020. https://www.wsj.com/articles/who-has-covid-19-what-we-know-about-tests-for-the-new-coronavirus-11585868185.
24. Centers for Disease Control and Prevention. “ICD-10-CM Official Coding and Reporting Guidelines April 1, 2020 through September 30, 2020.”
26. American Hospital Association. Coding Clinic for ICD-10-CM/PCS (First Quarter, 2014).
Cheryl Ericson (firstname.lastname@example.org) is clinical program manager at Iodine Software.
Continuing Education Quiz
Review quiz questions and take the quiz based on this article, available online.
- Quiz ID: Q2039107
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