April 10, 2020 | By Jill Young, CPC, CEDC, CIMC
The Centers for Disease Control and Prevention (CDC) released its ICD-10 documentation guidelines for COVID-19, using the newly adopted code U07.1. You can find the CDC’s guidance document here https://www.cdc.gov/nchs/data/icd/COVID-19-guidelines-final.pdf. The information shows an effective date range from April 1, 2020 through September 30, 2020. The document has instructions on coding only confirmed cases was presented remind us that “confirmation” does not require documentation of the type of test performed; that the provider’s personal documentation that the individual has COVID-19 is sufficient.
Presumptive positive cases of COVID-19 should also be coded as confirmed. This type of positive test is one that was done at the local or state level but has not yet been confirmed by the CDC. The agency no longer requires that it confirm a state or local test in order to assign a definitive diagnosis of COVID-19. Conversely, if the provider’s documentation uses words like “suspected,” “possible,” or “acts like,” do not assign U07.1. Rather, report diagnosis codes corresponding to the signs and symptoms that prompted the patient to present for the visit.
In terms of sequencing, if the new COVID-19 code meets the definition of a principal diagnosis, it should be first-listed, followed by the appropriate codes for associated manifestation(s), except in the case of obstetrical patients. For these cases, see Section I.C.15.s of the ICD-10-CM guidelines for instructions.
The remaining sections of the CDC document have coding instruction that address the proper way to code screening encounters for both patients who have confirmed exposure to COVID-19 (Z20.828) as well as for patients who have a possible exposure to COVID-19 (Z03.818). In such screening cases, these diagnoses should only be coded if the patient tests negative for COVID-19; if they test positive, then U07.1 would be coded instead. Lastly, it addresses how patients without a definitive diagnosis of COVID-19 who are seen with signs and symptoms would be coded.
The CDC document presents both the older guidance (effective from February 20, 2020 to March 31, 2020) alongside the most recent guidance superseding it (effective from April 1, 2020 to Sept. 30, 2020). Good luck!