Q&A: Charging an E/M service with wound debridement

Q: Which ICD-10-CM codes would we use to report an emergency department (ED) encounter for a patient presumed to have the novel coronavirus (COVID-19) who does not undergo diagnostic testing?

A: If the provider documented signs or symptoms that led to the presumed diagnosis of COVID-19, ICD-10-CM codes for those signs or symptoms should be assigned with additional code Z20.828 (contact with and [suspected] exposure to other viral communicable diseases).

Per the ICD-10-CM Official Guidelines for Coding and Reporting, presumptive positive COVID-19 test results should be coded as confirmed. However, in this example, a test was not performed, nor did a provider make a definitive diagnosis to allow reporting of ICD-10-CM code U07.1 (2019-nCoV acute respiratory disease). “Presumed,” in this instance, would be treated as an uncertain diagnosis. Only confirmed cases of COVID-19 may be reported.

Editor’s note: This question was answered by Yvette DeVay, MHA, CPC, CPMA, CIC, CPC-I, lead instructor for HCPro’s Medicare Boot Camp®—Physician Services Version, and Shannon McCall, RHIA, CCS, CCS-P, CPC, CEMC, CRC, CCDS, HCS-D, director of HIM and coding for HCPro in Middleton, Massachusetts, during the HCPro webinar, “COVID-19 Coding: The Latest on ICD-10-CM, CPT Reporting.”

This answer was provided based on limited information. Be sure to review all documentation specific to your own individual scenario before determining appropriate code assignment.