Use clear documentation guidance to capture COVID-19 diagnoses

With the release of a new ICD-10-CM code for the novel coronavirus (COVID-19), hospitals now have a method to capture and report this critical disease. Although the code itself is relatively straightforward and likely won’t stir up confusion the way coding for complex diagnoses (such as sepsis) does, correctly documenting and coding COVID-19 is crucial to turning the tide on the national public health emergency. All staff involved in documentation, from clinicians to coders, must keep several key points in mind.

Words matter

As COVID-19 spread around the globe earlier this year, the terminology used to describe the virus and the disease evolved. In the past several weeks, a general consensus was reached in that the virus would be described as COVID-19 and the infection would be referred to as COVID-19 infection. That’s no small feat in the medical world, where competing and conflicting terminology regularly snarl documentation, says Emmel Golden, MD, FCCP, CCDS, chief clinical officer for Enjoin in Eads, Tennessee.

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 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

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.

Clinical staff who frequently qualify their diagnoses with terms such as “probable,” “possible,” or “likely” should be advised to strike those words, Golden advises. If a patient’s discharge summary states “possible COVID-19 infection,” it won’t be coded as U07.1, and will instead 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 have ramifications beyond claims submission, Golden notes. It will affect data collection and reporting for public health agencies, research, and potentially activation of internal infection control protocols.

“If that’s your clinical impression, that should almost be the first thing on the chart so that the patient is handled in such a way to minimize potential spread to workers in the hospital,” Golden says. “Documentation is very key in establishing the behaviors that will help mitigate and limit the spread of this infection in the environment of a hospital.”

Another critical point is that a positive test result is not required for the diagnosis.

“If it’s your clinical opinion that the patient has a COVID-19 infection, don’t worry about if there’s a test,” Golden advises. “Make the diagnosis because it’s so important for a multitude of reasons in terms of knowing not only our immediate behavior but our ultimate understanding of this condition.”

Documentation takeaways

Coding and documentation guidance will continue to evolve, and staff will need to 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, Golden points out. “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 will 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, respiratory failure,” he says.

Although a positive test result isn’t required for a diagnosis, the physician should be queried if the medical record includes a positive test result but the diagnosis isn’t noted in the discharge summary, Golden says. As with any other clinical diagnosis, if the components of the syndrome are documented and the diagnosis could be clinically valid but the physician did not explicitly state the diagnosis, a multiple choice query should be sent.

Remind clinical staff that they shouldn’t hold off on making the diagnosis just because the patient hasn’t been tested and that they should avoid qualifying language such as “likely” or “possible.”

“I think one thing we can communicate through the CDI specialists and HIM professionals is that if this is your opinion, that’s all we need,” Golden says.