COVID-19 Explained: Coding COVID-19 Possible Infection & Symptoms

COVID-19 Explained: Coding COVID-19 Possible Infection & Symptoms


This article offers guidelines on Coding COVID-19 suspected Infection & Symptoms. After the outbreak of COVID-19, CDC issued coding guidelines and recommendations to isolate at home to prevent possible COVID-19 infection and inhibit the spread of the Coronavirus. In addition to the social distancing and stay-at-home orders, CDC released interim guidance on how to care for yourself or family at home who display COVID-19 symptoms but do not require hospitalization (CDC, 2020).

With the new ICD-10-CM Coding and Reporting Guidelines for COVID-19 active, sign up for the Respiratory Diagnoses Hot Topics Webinar and find out how to code Coronavirus infections, symptoms, and patient encounters. The webinar on hot coding topics provides an overview of the Official Coding Guidelines for COVID-19. See more here.

Who is at risk for possible COVID-19 infection?

The people who are at the highest risk for possible COVID-19 infection are older adults and people with underlying medical conditions, such as chronic lung disease, severe asthma, cardiac disease with complications, diabetes, immunocompromising diseases, and other chronic conditions (CMS, 2020). In addition, individuals who have been in close contact with infected or symptomatic patients without protection are at risk of becoming infected.

How to code the symptoms of COVID-19

coding covid-19This excerpt from the ICD-10-CM Official Coding and Reporting Guidelines outlines how to code possible Coronavirus infection (CDC, 2020):

“Code only a confirmed diagnosis of the 2019 novel coronavirus disease (COVID-19) as documented by the provider, documentation of a positive COVID-19 test result, or a presumptive positive COVID-19 test result. For a confirmed diagnosis, assign code U07.1, COVID-19. This is an exception to the hospital inpatient guideline Section II, H. In this context, “confirmation” does not require documentation of the type of test performed; the provider’s documentation that the individual has COVID-19 is sufficient.

“Presumptive positive COVID-19 test results should be coded as confirmed. A presumptive positive test result means an individual has tested positive for the virus at a local or state level, but it has not yet been confirmed by the Centers for Disease Control and Prevention (CDC). CDC confirmation of local and state tests for COVID-19 is no longer required.

“If the provider documents ‘suspected,’ ‘possible,’ ‘probable,’ or ‘inconclusive’ COVID-19, do not assign code U07.1. Assign a code(s) explaining the reason for encounter (such as fever) or Z20.828, Contact with and (suspected) exposure to other viral communicable diseases.”

Symptoms of the Coronavirus, according to the CDC, include cough, shortness of breath, fever, chills, muscle pain, headache, sore throat, and loss of taste and smell (2020). In patients with acute bronchitis that has been caused by COVID-19, use codes U07.1 and J20.8. For lower respiratory infection due to COVID-19, assign codes U07.1 and J22. Read our article, “CDC Releases Updated Coding & Reporting Guidelines for U07.1,” for the full guidelines for coding COVID-19 symptoms.

Part 1 in the “COVID-19 Explained” Series explores the Coronavirus’ history, and how to code suspected exposure to the virus. Part 3 discusses the codes to document and bill COVID-19 testing. Review our previous article for more information about the COVID-19 medical coding and reporting guidelines, which are effective April 1 through September 30.

The Respiratory Diagnoses Hot Topics Webinar provides an overview of the Official Coding Guidelines for COVID-19, as well as how to code the Coronavirus infections, symptoms, and patient encounters. See more here.

YES HIM Consulting

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