CDC Final Guidelines for COVID-19 Documentation in Health Care Facilities (ICD-10-CM coding)

Alaska Department of Health sent this bulletin at 04/15/2020 07:13 PM AKDT

COVID-19

COVID-19 Update for Alaska’s Health Care Providers: 

CDC Final Guidelines for COVID-19 Documentation in Health Care Facilities

(ICD-10-CM coding)

April 15, 2020

This is an update to the email dated March 24, 2020 regarding interim COVID-19 ICD-10-CM coding of medical encounters at health care facilities to provide the final coding guidance.  We also want to clarify that it does NOT apply to death certificates.  Thank you for your assistance in ensuring we have accurate counts of suspected and confirmed COVID-19 cases in medical billing data.
The CDC has released the attached guidance for hospital personnel to accurately document medical encounters related to coronavirus disease (COVID-19). We have summarized key points from this guidance, which outlines the final ICD-10-CM coding to use for COVID-19 encounters:
a) Code only confirmed cases
  • A confirmed case is documented by the provider of a positive COVID-19 test result or a presumptive positive COVID-19 test result.  These cases should be assigned code U07.1, COVID-19
  • If the provider documents “suspected”, “possible”, “probable” or “Inconclusive” COVID-19, do not use code U07.1.

b) Sequencing of codes

  • When COVID-19 meets the definition of primary diagnosis, code U07.1 should be sequenced first, followed by the appropriate codes for associated manifestations, except in the case of obstetric patients. 

c) Acute respiratory illness due to COVID-19

  • Some examples follow. Please refer to the guidance for more information.
  • Acute respiratory Illness due to COVID-19
    • Pneumonia - U07.1, COVID-19 and J12.89, “Other viral pneumonia”.
    • Acute bronchitis - U07.1, COVID-19 and J20.8, “Acute bronchitis due to other specified organisms”.
    • Acute respiratory distress syndrome (ARDS) - U07.1, COVID-19 and J80, “Acute respiratory distress syndrome”.

d) Exposure to COVID-19

  • For possible exposure but COVID-19 was ruled out, use Z03.818 “Encounter for observation for suspected exposure to other biological agents ruled out”
  • For actual exposure to someone with confirmed COVID-19, use Z20.828 “Contact with and (suspected) exposure to other viral communicable diseases”

e) Screening for COVID-19

  • For asymptomatic individuals who are being screened for COVID-19 and have no known exposure, and the test results are either unknown or negative, assign code Z11.59, “Encounter for screening for other viral disease”. 

f) Signs and Symptoms without definitive diagnosis of COVID-19

  • When a definitive diagnosis has not been established, use R05 “Cough”, R06.02 “Shortness of breath”, R50.9 “Fever, unspecified”

g) Asymptomatic individuals who test positive for COVID-19

  • Assign code U07.1, COVID-19.  Although they are asymptomatic, the person is considered to have the COVID-19 infection.

Please note, we did not provide a complete interpretation of the guidelines in this summary.

We realize that the first priority for health care providers and health care facilities is to provide quality and timely care to those who need it most.  For this reason, we want to provide this concise and clear information to help identify COVID-19 cases in Alaska during the COVID-19 outbreak.

Thank you for your dedication and service to Alaskan communities. 

For questions, email DHSSEOC@alaska.gov.

Please check the DHSS Human Coronavirus website and the CDC COVID-19 website frequently for the latest information.