Guidance for Documenting COVID-19 Diagnoses

I was recently interviewed for the March issue of Revenue Integrity Insider on guidance for documenting COVID-19. The following blog post covers some of the key points discussed. 

Starting April 1, organizations will report COVID-19 infections using ICD-10-CM code U07.1 (2019-nCoV acute respiratory disease). The code should be simple for staff to learn, but it is important to ensure documentation is unambiguous as well.

Here are three key points to keep in mind when documenting COVID-19.

 

Words matter

To keep terminology consistent at your organization, ensure that clinical, CDI and HIM staff, as well as any other staff involved in processing medical records and claims, understand the two COVID-19 terms and how they’re used. This should be a simple task, now that the terminology is relatively straightforward, but ensure that reference material on the naming conventions is easily available.

 

Be decisive

Clinical staff who frequently qualify their diagnoses with terms such as “probable,” “possible” or “likely” should be advised to strike those words. If a patient’s discharge summary states “possible COVID-19 infection,” it won’t be coded correctly as U07.1. Instead, it will be assigned Z20.828 (contact with and [suspected] exposure to other viral communicable diseases) or Z03.818 (encounter for observation for suspected exposure to other biological agents ruled out). And missing that diagnosis and code has ramifications beyond claims submission. It will affect data collection and reporting for public health agencies, research, and potentially activation of internal infection control protocols. I can’t stress enough the importance of being decisive when documenting COVID-19 diagnoses.

 

Remember principal diagnosis

As coding and documentation guidance continues to evolve, staff must be immediately alerted to changes. On March 25, the CDC issued guidance on coding COVID-19 infections. When a COVID-19 infection is present and the patient is admitted to the hospital because of a COVID-19 infection manifestation, U07.1 should be reported as the principal diagnosis.

A COVID-19 infection on its own will likely not be the reason for hospitalization. Keep in mind that for people with COVID-19 infection, the goal is to keep them out of the hospital. And fortunately, the vast majority of people who have a COVID-19 infection will stay at home. They’re not being admitted because they have a COVID-19 infection. They’re being admitted because they have a problem like hypoxia, viral pneumonia or respiratory failure.

You can view the complete Revenue Integrity Insider article on documenting COVID-19 here.

 

NAHRI members can share information and ask questions about COVID-19-related revenue integrity concerns on our dedicated COVID-19 forum. Nonmembers may use HCPro’s COVID-19 forum by registering free of charge. Visit our Coronavirus Resource Center for additional guidance and education. Email NAHRI Director Jaclyn Fitzgerald at jfitzgerald@hcpro.com with requests for additional COVID-19 resources and news.