10 Tips And Pointers for Physician Advisors About Documentation of Covid-19

By Erica Remer, MD, CCDS

1. The World Health Organization’s ICD-10 lifted their code set freeze for this pandemic and created U07.1, COVID-19, virus identified. In a matter of weeks, in an unprecedented fashion, the United States imported this code into ICD-10-CM (the US’ version with clinical modification) as of April 1, 2020. Unfortunately, we did not incorporate U07.2, COVID-19, virus not identified which would have signaled infection that is not test-proven.

2. Coders are entitled to refuse to code U07.1 from documentation of “COVID” without the “-19” at the end. Right now, it is the only COVID we are dealing with, but in the future, we may have more. Use “COVID-19” at least once in your documentation during the encounter, or, easier still, make a macro where you type in “c19” and it expands to “COVID-19”

3. COVID-19 is an exception to the uncertain diagnosis rule. If an uncertain modifier, such as, “possible, probable, likely” is used with COVID-19, only the manifestation and/or symptoms would get coded for the disease process. The exception to this is on a death certificate. If you document it as an uncertain diagnosis on a death certificate, it will be picked up as COVID-19 (death certificates use ICD-10, not ICD-10-CM, so they have U07.2).

4. The PCR test has a 30% false negative rate. If your pre-test probability is high, a negative test should not be used to rule out the disease. This means there are patients with negative tests who clinicians are diagnosing anyway as having COVID-19. Perfectly acceptable.

5. As per #4, providers are allowed to diagnose COVID-19 clinically, is so inclined. If a provider is making a diagnosis on clinical grounds, I recommend that they document: “COVID-19 based on clinical judgment.” Uncertain diagnoses do not get coded with U07.1; they are coded with the manifestation/signs/symptoms plus a code indicating exposure to the virus. Auditors are going to be trying to deny the validity of cases without test confirmation. Don’t give them fodder.

6. Don’t use the word, “presumed,” to indicate “presumptive” or to convey an uncertain diagnosis. For public health purposes (prior to March 14), “presumptive” meant that the local, regional, or state PCR test was positive but not confirmed by CDC testing. Any positive PCR test is considered a confirmed COVID-19 infection.

7. Best practice is to draw a conclusion about the symptoms that represents the manifestation that the virus is causing in the patient. Rather than concluding, “Cough,” document “acute bronchitis.” If the patient is having abdominal discomfort and diarrhea, document “viral enteritis.”

8. Linkage is important. Do you think that DVT or stroke is due to the COVID-19? In the AIDS patient who also has COVID-19, which infection do you think is causing the pneumonia? Words or phrases which signal linkage: due to, from, as a result of, secondary to, etc.. They must clearly demonstrate a causal relationship.

9. Make the non-respiratory symptoms line-items in your impression/diagnosis list. The coder will pick them up, and then we will be able to track them epidemiologically. A great example is “loss of taste and smell due to COVID-19.”

10. Try not to use the word, “screening.” Screening is when public health officials arrange for mass testing of an asymptomatic population to try to pick up a disease or genetic state which is not expected or to which there has been no known exposure, in order to diagnose and treat it early. We are testing people because we have a concern that there may have been exposure or an asymptomatic infection. It matters because there is a different code for exposure vs. screening.