When a patient is diagnosed with COVID-19, we understand that signs and symptoms are not manifestations and would not be separately coded. We also understand that Guideline I.C.18.b. states that “signs or symptoms that are routinely associated with a disease process should not be assigned as additional codes, unless otherwise instructed by the classification.” When a patient diagnosed with COVID-19 presents with both respiratory signs/symptoms (e.g., shortness of breath, cough) and non-respiratory signs/symptoms (e.g. gastrointestinal problems, dermatologic or venous sufficiency issues), may the non-respiratory signs/symptoms/conditions be coded separately since they are not routinely associated with COVID-19? (4/28/2020; revised 8/25/21)
People infected with COVID-19 may vary from being asymptomatic to having a range of symptoms and severity. Therefore, for coding purposes, signs and symptoms associated with COVID-19 may be coded separately, unless the signs or symptoms are routinely associated with a manifestation. For example, cough would not be coded separately if the patient has pneumonia due to COVID-19, as cough is a symptom of pneumonia. The additional coding of signs or symptoms not explained by the manifestations would provide additional information on the severity of the disease.
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; revised 12/11/2020, 8/25/21)
Assign code M35.8, Other specified systemic involvement of connective tissue, for discharges prior to January 1, 2021, or code M35.81, Multisystem inflammatory syndrome, for discharges after January 1, 2021, as the principal diagnosis, for the MIS-C, and code B94.8, Sequelae of other specified infectious and parasitic diseases, for discharges/encounters prior to October 1, 2021, or code U09.9, Post COVID-19 condition, unspecified, for discharges/encounters on or after October 1, 2021, 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 ICD-10-CM Official Guidelines for Coding and Reporting, the provider’s documentation that the individual has COVID-19 is sufficient for coding purposes.
The patient presents to the facility with symptoms such as generalized weakness and lack of appetite, and the provider documents a diagnosis of “post COVID-19 syndrome.” How should this be coded? (12/11/2020; revised 8/25/21)
For discharges/encounters on or after October 1, 2021, assign codes R53.1, Weakness, R63.0, Anorexia, and U09.9, Post COVID-19 condition, unspecified, for a diagnosis of post COVID-19 syndrome with generalized weakness and lack of appetite This is supported by the instructional note at code U09.9 to “code first the specific condition related to COVID-19 if known.”
[Prior to 10/1/21:]
For discharges/encounters prior to October 1, 2021, unless the provider specifically documents that the symptoms are the result of COVID-19, assign code(s) for the specific symptom(s) and a code for personal history of COVID-19. “Post COVID-19 syndrome” indicates temporality, but not that the current symptom(s) or clinical condition(s) are a residual effect (sequelae) of COVID-19. As stated in the ICD-10-CM Official Guidelines for Coding and Reporting, in the absence of Alphabetic Index guidance for coding syndromes, assign codes for the documented manifestations of the syndrome.
The appropriate personal history code is Z86.19, Personal history of other infectious and parasitic diseases, for discharges/encounters prior to January 1, 2021 or code Z86.16, Personal history of COVID-19, for discharges/encounters after January 1, 2021.
If the provider documents that the symptoms are the result (residual effect) of COVID-19, assign code(s) for the specific symptom(s) and code B94.8, Sequelae of other specified infectious and parasitic diseases. According to the ICD-10-CM Official Guidelines for Coding and Reporting, a sequela is the residual effect (condition produced) after the acute phase of an illness or injury has terminated.
A patient was COVID-19 positive at a short term acute care hospital where he was being cared for COVID-19 related respiratory problems and completed treatment with Remdesivir and Dexamethasone. After more than a two-month stay, the patient is now transferred to a long-term care hospital (LTCH) with acute respiratory failure for tracheostomy weaning. At the time of transfer, the patient had been weaned from ventilator to tracheostomy collar at 28%. Diagnosis on admission was history of COVID-19, acute respiratory failure, and tracheostomy dependence. When queried regarding the patient’s COVID-19 status on admission to the LTCH, the provider indicated that the patient was no longer infectious and is being admitted only to treat the residual respiratory failure requiring oxygenation via tracheostomy. May we assign code J96.90 as a principal diagnosis, followed by code Z86.16, Personal history of COVID-19, since the patient no longer has a COVID-19 infection? (3/1/21; revised 8/25/21)
Query the provider whether “residual respiratory failure” refers to acute on chronic, or chronic respiratory failure. Assign the appropriate respiratory failure code based on the response, followed by code B94.8, Sequelae of other specified infectious and parasitic diseases, for discharges/encounters prior to October 1, 2021, or code U09.9, Post COVID-19 condition, unspecified, for discharges/encounters on or after October 1, 2021, as a secondary diagnosis, for the sequelae of COVID-19 infection, since the patient has been documented as no longer infectious for COVID-19.
Although the provider referred to “history of COVID-19,” a personal history code is inappropriate in this case. As defined in the ICD-10-CM Official Guidelines for Coding and Reporting, Section IB. “A sequela is the residual effect (condition produced) after the acute phase of an illness or injury has terminated.” In addition, Section I. C.21,c,( 4) states “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.”
Patient has a long history of multiple transfers between short term acute care hospitals (STACH) and long-term care hospitals (LTCH) for nearly 8 months. Patient is status post prolonged hospitalizations for respiratory failure and critical illness secondary to COVID-19 pneumonia. He never fully recovered from a respiratory standpoint. He is now admitted into the LTCH with COVID-19 listed as past history for continued treatment of respiratory failure with prolonged mechanical ventilation for further continuation of vent weaning and rehab services. COVID-19 treatment was completed 8 months ago at the STACH.
Provider documentation states chronic respiratory failure secondary to COVID-19 related ARDS, and status post tracheostomy. Patient is currently on prolonged mechanical ventilation most likely from diaphragm weakness and tenacious secretions complicated by pulmonary hypertension with some degree of prominent lung dysfunction. Would the correct coding and sequencing for the above scenario be J96.10, Chronic respiratory failure, followed by Z86.16, for history of COVID, or B94.8 for sequela of COVID? (3/1/21; revised 8/25/21)
Assign code J96.10, Chronic respiratory failure, unspecified whether with hypoxia or hypercapnia, as the principal diagnosis since the ARDS has resolved. In addition, assign code B94.8, Sequelae of other specified infectious and parasitic diseases, for discharges/encounters prior to October 1, 2021, or code U09.9, Post COVID-19 condition, unspecified, for discharges/encounters on or after October 1, 2021, as a secondary diagnosis, since the patient no longer has an active COVID-19 infection.
A patient who tested negative for COVID-19 several times as an outpatient now presents to the Emergency Department because of worsening symptoms. The patient was admitted for treatment of possible pneumonia. He was retested for COVID-19, and the results were still negative; however, a COVID-19 antibody test was positive. The provider’s final diagnostic statement lists, “Post COVID-19 organizing pneumonia.” Would pneumonia be considered an acute manifestation of COVID-19, a late effect/sequela of COVID- 19, or is the COVID-19 coded as a personal history since the most recent COVID-19 test is negative? What is the principal diagnosis, COVID-19 or pneumonia? (3/1/21; revised 8/25/21)
Based on the documentation provided, the patient has an organizing pneumonia due to previous COVID-19 infection. Assign code J84.89, Other specified interstitial pulmonary diseases, followed by code B94.8. Sequelae of other specified infectious and parasitic diseases, for discharges/encounters prior to October 1, 2021, or code U09.9, Post COVID-19 condition, unspecified, for discharges/encounters on or after October 1, 2021, for a diagnosis of post COVID-19 organizing pneumonia. Code J84.89 may be located by the following Index entry:
A patient with a history of COVID-19 infection was admitted for treatment of acute hyperkalemia and acute kidney injury with chronic kidney disease. Follow-up COVID-19 testing was positive. The provider documented, “COVID likely reflective of old noninfectious virus.” How is the COVID-19 status captured for this patient? Does the Official Coding and Reporting Guideline I.C.1.g.1.a., “code only confirmed cases” apply when the provider documents the patient as “noninfectious” but has a positive COVID-19 test during the admission? (8/25/21)
Assign code Z86.16, Personal history of COVID-19. While the patient had a positive COVID-19 test, the provider documented that the patient was not actively infectious during this admission. When the provider documents “noninfectious” or “not infectious” COVID-19 status, this indicates that the patient no longer has an active COVID-19 infection, therefore assign code Z86.16 instead of code U07.1, COVID-19.
Although guideline I.C.1.g.1.a., states: “Code only a confirmed diagnosis of the 2019 novel coronavirus disease (COVID-19) as documented by the provider or documentation of a positive COVID-19 test result,” in this scenario the provider has clarified the patient no longer has an active COVID-19 infection. Therefore, code U07.1, COVID-19, is not appropriate and the Official Coding Guideline I.C.1.g.1.a., regarding a positive COVID-19 test result would not apply.
If the documentation is unclear, as to whether the patient has an active COVID-19 infection or a personal history, query the provider for clarification.
A patient presented to the hospital with acute respiratory failure and COPD exacerbation. It was noted that the patient tested positive for COVID-19 approximately 80 days prior to this admission. A repeat COVID-19 test was performed and came back positive but the provider documented she did not consider the patient’s status to be a COVID-19 “reinfection.” The discharge summary states: “history of COVID infection currently still testing positive for COVID.” Is it appropriate to assign code Z86.16, Personal history of COVID-19, or code U07.1, COVID-19 since there is a positive test? (8/25/21)
Although the patient is still testing positive for COVID-19, the provider has documented the patient’s condition was a previous history of a COVID-19 infection and not a reinfection, therefore it would be appropriate to assign code Z86.16, Personal history of COVID-19.
A patient presented for treatment of bulbous pemphigoid bulla with surrounding cellulitis. During the admission, the patient was tested for COVID-19. Although the patient was completely vaccinated, the physician documented the COVID-19 test was positive. The patient was subsequently placed in isolation and instructed to complete 10 days of self-isolation following discharge. How is COVID-19 coded in this scenario? (8/25/21)
Assign code U07.1, COVID-19. The provider’s assessment stated “COVID-19 virus detected,” and it is possible for a COVID-19 infection to occur despite vaccination. This is consistent with Official Guidelines for Coding and Reporting, Section I.C.1.g.1.a., which states: Code only a confirmed diagnosis of the 2019 novel coronavirus disease (COVID-19) as documented by the provider or documentation of a positive COVID-19 test result.
A patient was recently discharged from the hospital, admitted to a nursing home, and subsequently tested positive for COVID-19 via a rapid antigen test. The patient was readmitted to the hospital for COVID-19; however was asymptomatic. Repeat testing x2 including confirmatory testing of COVID PCR was negative. The provider consulted with infectious disease and hematology and it was documented the patient had a false positive that did not represent a true COVID-19 infection. How is COVID-19 coded in this scenario? (8/25/21)
Assign code Z20.822, Contact with and (suspected) exposure to COVID-19, as principal diagnosis, for a patient admitted and found to have a false positive COVID-19 test. ICD-10-CM Official Guidelines for Coding and Reporting, Section I.C.1.g.1.e. states: For asymptomatic individuals with actual or suspected exposure to COVID-19, assign code Z20.822, Contact with and (suspected) exposure to COVID-19.
Although guideline I.C.1.g.1.a., allows coding of confirmed cases of COVID-19 on the basis of “documentation of a positive COVID-19 test result,” in this scenario the provider clarified the COVID-19 test as being a false positive; therefore code U07.1, COVID-19, is not appropriate and the Official Coding Guideline I.C.1.g.1.a. regarding coding on the basis of a positive COVID-19 test result would not apply to this case.
However, it is always appropriate to query the provider for clarification whenever the coding professional finds the medical record documentation to be unclear regarding the patient’s COVID-19 status.
Is it appropriate to report code Z28.3, Underimmunization status, for encounters where the provider documents the patient has not been immunized against COVID-19?? (8/27/21).
No, code Z28.3, Underimmunization status, is not appropriate for this purpose. There is currently no ICD-10-CM code available to identify lack of immunization against COVID-19.
What ICD-10-PCS procedure code should be assigned for a new drug or other therapeutic substance administered in the hospital inpatient setting to treat COVID-19 when there is no unique code for the administration of the specific substance? (7/30/2020; revised 8/5/2020, 8/25/21)
Effective with discharges on or after August 1, 2020, the following ICD-10-PCS codes should be used for administration of a new therapeutic substance to treat COVID-19 when the substance is not classified elsewhere in ICD-10-PCS:
These codes should only be assigned for new therapeutic substances being used to treat COVID-19. For administration of “other therapeutic substances” that are being used to treat medical conditions other than COVID-19, see ICD-10-PCS table 3E0. For example, code 3E033GC describes “Introduction of Other Therapeutic Substance into Peripheral Vein, Percutaneous Approach.”