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This webinar addresses coding direction for confirmed, suspected and ruled-out COVID-19 cases. Watch the webinar and refer to the chartbook. Then quiz yourself using our Knowledge Checks document. 

Transcript

Slide 1: ICD-10-CA Coding Direction for COVID-19

  • Hello everyone. Thank you for joining us for today’s webinar, ICD-10-CA Coding Direction for COVID-19.

Slide 2: Learning objectives

  • Today, we are going to cover confirmed and suspected COVID-19, cases of ruled-out COVID-19, the use of COVID-19 lab test results to inform code assignment and other COVID-19–related cases.
  • We will go through some examples and then we will give you an opportunity to apply this knowledge to some questions.

Slide 3: COVID-19 coding direction: Bulletins

  • Classifications and Terminologies has released 3 bulletins that provide ICD-10-CA coding direction for COVID-19 cases, as shown on this slide.
  • The most recent bulletin was released on April 30, 2020. It provides coding direction for COVID-19 in obstetrics, and updates on the use of COVID-19 laboratory test results.
  • All 3 bulletins are available on our website on both the Codes and Classifications web page and the COVID-19 resources page. Remember to visit these web pages from time to time for the most recent COVID-19 information.

Slide 4: COVID-19

  • A confirmed case of COVID-19 is one for which there is a positive COVID-19 lab test result.
  • A suspected COVID-19 case is one that has been diagnosed clinically or epidemiologically but for which COVID-19 lab test results are inconclusive or not available, or for which COVID-19 testing has not been performed.

Slide 5: Confirmed COVID-19

  • A lab-confirmed case of COVID-19 is classified to U07.1 COVID-19, virus identified.
  • Additional codes are assigned for any manifestations, such as pneumonia, that meet the definition of diagnosis type (1) or diagnosis type (2).
  • U07.1 is assigned only when COVID-19 is lab confirmed.

Slide 6: Suspected COVID-19

  • A suspected COVID-19 case is classified to U07.2 COVID-19, virus not identified.
  • U07.2 is assigned when COVID-19 is diagnosed clinically or epidemiologically and COVID-19 lab test results are inconclusive or not available, or when COVID-19 testing is not performed.

Slide 7: Canadian Emergency Department Diagnosis Shortlist (CED-DxS)

  • The CED-DxS is used to capture emergency department discharge diagnoses in NACRS. The codes to identify confirmed and suspected COVID-19 were added to the pick-list and the CED-DxS–SNOMED CT maps in April 2020.

Slide 8: Use of COVID-19 lab results for coding

  • Coders who are completing DAD or NACRS abstracts may use COVID-19 lab test results to inform code assignment to confirm or to rule out COVID-19.
  • The lab test results may be used only to confirm COVID-19 and not to determine any other organism causing the disease.
  • This is an exception to the direction provided in the coding standard Using Diagnostic Test Results in Coding.
  • Use physician or infection control documentation of COVID-19 lab test results, even when the lab report is not available.
  • Per usual coding practice, physician documentation of a positive or negative COVID-19 lab test result is sufficient to inform code assignment. In this case, you do not have to access the COVID-19 lab report.
  • When documentation supports that it is a suspected COVID-19 case, use the most recent COVID-19 lab test results from a continuous, uninterrupted episode of care, when available, to confirm or rule out COVID-19.
  • We recommend that coders code charts when lab test results are available; alternatively, coders can flag coded charts and update the code assignment accordingly once lab test results become available. While this is most relevant to emergency department coding, it may also apply to acute care inpatient abstracts when COVID-19 lab results are not available at the time of discharge.

Slide 9: Use of COVID-19 lab results for coding

  • For continuous, uninterrupted episodes of care, COVID-19 lab results that qualify for use can originate from an
    • Assessment centre, to inform COVID-19 code assignment for an emergency department or an acute care inpatient episode of care
    • Emergency department, to inform COVID-19 code assignment for an acute care inpatient episode of care
    • Acute care inpatient episode of care, to inform COVID-19 code assignment for an emergency department episode of care

Slide 10: COVID-19 diagnosis typing

  • We’ll now take a look at diagnosis typing applied to a COVID-19 case.

Slide 11: Diagnosis typing

  • Diagnosis typing depends on the clinical documentation and the specific circumstances of the episode of care.
  • In most cases, U07.1 or U07.2 will be the most responsible diagnosis or main problem. However, there are circumstances where another code may qualify as the most responsible diagnosis or main problem.
  • Do not apply prefix Q to U07.1 or U07.2.
  • When applicable, apply a significant diagnosis type to any manifestations, such as pneumonia.
  • There are circumstances when U07.1 or U07.2 is not the most responsible diagnosis, such as an obstetrical case, a transfer for convalescence and an admission solely for palliative care.
  • We will take a look at some of these scenarios later in the presentation.

Slide 12: Knowledge check 1

  • We will now pause for a couple of knowledge checks to give you an opportunity to apply what we have covered so far.

Slide 13 Knowledge check 1: Scenario

  • Here are the facts of the case: The patient presents to the emergency department with a dry cough, shortness of breath and a fever. The patient’s spouse tested positive for COVID-19 1 week ago. COVID-19 testing is not performed on this patient. The patient is discharged home with instructions to self-isolate and to return if signs and symptoms worsen.
  • The final diagnosis is COVID-19.

Slide 14: Knowledge check 1: Question and options

  • Which code is assigned as the main problem for the emergency department episode of care?
  • The options are
  1. R05 (MP) Cough
  2. U07.1 (MP) COVID-19, virus identified
  3. U07.2 (MP) COVID-19, virus not identified

Slide 15: Knowledge check 1: Answer and rationale

  • The correct answer is c) U07.2 (MP) COVID-19, virus not identified.
  • COVID-19 testing was not performed on this patient.
  • This patient was diagnosed with COVID-19 based on the clinical assessment (that is, the presenting signs and symptoms) and known exposure to someone who tested positive for COVID-19.
  • U07.2 is assigned when COVID-19 is diagnosed clinically or epidemiologically and testing is not performed.

Slide 16: Knowledge check 2

  • We will now move on to the second knowledge check.

Slide 17: Knowledge check 2: Scenario

  • Here are the facts of the case: The patient presents to a COVID-19 assessment centre for testing. The patient is then referred to the emergency department with shortness of breath, a fever and a cough. The patient is discharged home with instructions to self-isolate and to return to the emergency department if signs and symptoms worsen.
  • The final diagnosis is suspected COVID-19.
  • The COVID-19 assessment centre lab test results, which are available to the coder, come back positive for COVID-19.

Slide 18: Knowledge check 2: Question and options

  • Which code is assigned as the main problem for the emergency department episode of care?
  • The options are
  1. R06.0 (MP) Dyspnoea
  2. U07.1 (MP) COVID-19, virus identified
  3. U07.2 (MP) COVID-19, virus not identified

Slide 19: Knowledge check 2: Answer and rationale

  • The correct answer is b) U07.1 (MP) COVID-19, virus identified.
  • COVID-19 testing was performed and it came back positive.
  • Coders may use COVID-19 lab test results, when available, to inform code assignment.
  • U07.1 is assigned only when confirmed by a positive COVID-19 lab result.

Slide 20: COVID-19: Ruled out

  • We have reviewed some suspected and confirmed COVID-19 cases; we will now move on and take a look at some scenarios where COVID-19 has been ruled out.

Slide 21: Ruled-out COVID-19: Signs and symptoms

  • In this scenario, the patient presents with a cough. A nasopharyngeal swab for COVID-19 is taken.
  • The final diagnosis is rule out COVID-19.
  • The COVID-19 lab test results are available to the coder and are negative.
  • Code assignment is Z03.8 Observation for other suspected diseases and conditions.
  • The Admission for Observation coding standard applies because the 3 criteria have been met:
    • Suspected COVID-19 was ruled out; and
    • There is no documentation to support that further investigation is required; and
    • Another underlying condition was not diagnosed.

Slide 22: Ruled-out COVID-19: Screening for COVID-19

  • In this scenario, the patient is contacted by public health because of possible exposure to COVID-19. A nasopharyngeal swab for COVID-19 is taken. There is no documentation to support that the patient has any signs or symptoms.
  • The final diagnosis is possible exposure to COVID-19.
  • The COVID-19 lab test results are available to the coder and are negative.
  • Code assignment is Z11.5 Special screening examination for other viral diseases.
  • The Screening for Specific Diseases coding standard applies. COVID-19 testing was performed because of possible exposure, prior to the onset of signs or symptoms, to enable early detection before the COVID-19 (if diagnosed) becomes serious.

Slide 23: Ruled-out COVID-19: Confirmed underlying condition

  • In this scenario, the patient is diagnosed with influenza-like illness, or ILI, and suspected COVID-19. A nasopharyngeal swab for COVID-19 is taken.
  • The final diagnosis is ILI/rule out COVID-19.
  • The COVID-19 lab test results are available to the coder and are negative.
  • Code assignment is J11.1 Influenza with other respiratory manifestations, virus not identified.
  • The Admission for Observation coding standard does not apply. When suspected COVID-19 is ruled out and the patient is diagnosed with another condition that explains the presenting signs and symptoms, the ICD-10-CA code for the other condition is assigned. Z03.8 is not assigned in this circumstance because the 3 criteria have not been met. Another underlying condition was diagnosed. This patient was diagnosed with influenza-like illness.

Slide 24: Re-testing following previous positive COVID-19

  • In this scenario, the patient previously tested positive for COVID-19. The patient now presents for follow-up COVID-19 re-testing to get clearance to return to work.
  • The final diagnosis is COVID-19 re-testing.
  • COVID-19 lab test results are available to the coder and are negative.
  • Code assignment is Z09.9 Follow-up examination after unspecified treatment for other conditions.
  • The Admission for Follow-Up Examination coding standard applies. The patient previously tested positive for COVID-19. The patient now presents for routine investigation to assess their status. The patient is exhibiting no signs or symptoms of COVID-19. The negative COVID-19 lab test result indicates no need for further treatment.

Slide 25: Ruled-out COVID-19: Non-medical issue

  • In this scenario, the patient is concerned that she has COVID-19. The patient presents with no known exposure and no signs or symptoms.
  • The final diagnosis is non-medical issue, concern for COVID-19.
  • COVID-19 lab testing was not performed.
  • Code assignment is Z71.1 Person with feared complaint in whom no diagnosis is made.
  • No coding standard is applicable. There is no documentation to support that there is a clinical reason for the patient’s concern.

Slide 26: COVID-19 in obstetrics

  • We’ll now take a look at COVID-19 in obstetrics.

Slide 27: COVID-19 coding direction: Obstetrical cases

  • COVID-19 poses a potential risk to maternal and fetal well-being. Therefore, the direction in the coding standard Complicated Pregnancy Versus Uncomplicated Pregnancy applies.
  • When COVID-19 is confirmed in obstetrics (with a positive COVID-19 lab test result), assign
    • O98.5– Other viral diseases complicating pregnancy, childbirth and the puerperium as the most responsible diagnosis or diagnosis type (1) or diagnosis type (2) or main problem (MP) or other problem (OP); and
    • U07.1 COVID-19, virus identified as a diagnosis type (3) or other problem.
  • When COVID-19 is suspected in obstetrics — that is, it was diagnosed clinically or epidemiologically and COVID-19 lab test results are inconclusive or not available, or COVID-19 testing was not performed — assign
    • O98.5– Other viral diseases complicating pregnancy, childbirth and the puerperium as the most responsible diagnosis or diagnosis type (1) or diagnosis type (2) or main problem (MP) or other problem (OP); and
    • U07.2 COVID-19, virus not identified as a diagnosis type (3) or other problem.
  • Per the “use additional code to identify specific condition” note at category O98 and the Use Additional Code/Code Separately Instructions coding standard, it is mandatory to also assign U07.1 or U07.2, respectively.
  • When suspected COVID-19 is ruled out, classify the case per the physician’s documented diagnosis.

Slide 28: COVID-19 and palliative care

  • Now on to another scenario that may occur with a COVID-19 case: palliative care.

Slide 29: COVID-19 coding direction: Palliative care

  • In this scenario, the patient presents to the emergency department with acute respiratory failure. A COVID-19 nasopharyngeal swab is taken. The patient is admitted to an acute care inpatient bed solely for comfort care.
  • The final diagnosis is COVID-19.
  • COVID-19 lab test results are available to the coder and are positive.
  • Code assignment is Z51.5 Palliative care as the most responsible diagnosis and U07.1 COVID-19, virus identified as a diagnosis type (3).
  • The Palliative Care coding standard applies. It is mandatory to assign Z51.5 Palliative care when there is physician documentation of palliative care. Palliative care documentation includes “palliative patient,” “end-of-life care,” “compassionate care” and “comfort care.” When the sole purpose of admission is palliative care, apply the most responsible diagnosis to Z51.5. It is mandatory to assign an additional code to describe the palliative condition; in this case, U07.1 is assigned to identify that confirmed COVID-19 is the palliative condition. Diagnosis type (3) is applied to U07.1 because the sole purpose of the episode of care was palliative care; COVID-19 did not meet the criteria for significance for this case.

Slide 30: COVID-19 in convalescence

  • We will now move on to today’s final COVID-19 scenario: convalescence.

Slide 31: COVID-19 coding direction: Admission for convalescence

  • In this scenario, the patient has surgery at Facility A and is transferred to Facility B for convalescence. As a precaution, because of the COVID-19 pandemic, the patient is admitted to a designated isolation unit for the first 14 days of this episode of care.
  • The final diagnosis is convalescence.
  • COVID-19 lab testing was not performed.
  • Code assignment is Z54.0 Convalescence following surgery, the ICD-10-CA code for the condition requiring convalescence as a diagnosis type (3) and Z29.0 Isolation, optionally, as a diagnosis type (3).
  • The Admission for Convalescence coding standard applies. When a patient is transferred solely to receive care in the recovery phase following treatment, assign a code from category Z54 Convalescence as the most responsible diagnosis and assign an additional code, mandatory, as a diagnosis type (3) to identify the condition for which convalescence is required.
  • COVID-19 codes are not assigned in this case.

Slide 32: Knowledge check 3

  • We will take a look at the third and final knowledge check for today.

Slide 33: Knowledge check 3: Scenario

  • Here are the facts of the case: The patient presents to a COVID-19 assessment centre for testing. The patient is referred to the emergency department with shortness of breath, a dry cough and a fever. The patient is admitted with acute respiratory failure and is intubated and ventilated. The prognosis is discussed with the family and determined to be poor. The patient is extubated on day 5 and comfort measures are implemented. The patient passes on day 7. The physician documents that lab results are positive for COVID-19.
  • The final diagnosis is COVID-19.
  • The COVID-19 lab results are not available to the coder; they are not filed on the patient’s chart.

Slide 34: Knowledge check 3: Question and options

  • Which code is assigned as the most responsible diagnosis?
  • The options are
  1. J96.09 (M) Acute respiratory failure, type unspecified
  2. U07.1 (M) COVID-19, virus identified
  3. U07.2 (M) COVID-19, virus not identified
  4. Z51.5 (M) Palliative care

Slide 35: Knowledge check 3: Answer and rationale

  • The correct answer is b) U07.1 (M) COVID-19, virus identified.
  • The COVID-19 lab test result is not available to the coder, but the physician documented that the COVID-19 lab test result was positive.
  • Physician documentation of COVID-19 lab results is sufficient to inform code assignment. The coder does not have to check for the COVID-19 lab results.
  • COVID-19 meets the criteria for the most responsible diagnosis.

Slide 36: How can clinicians help ensure that data supports monitoring?

  • One of the challenges a coder faces is incomplete or ambiguous clinical documentation.
  • To help ensure that COVID-19 data supports monitoring, CIHI released this infographic, which can be shared with clinicians to help support clear documentation of COVID-19–related diagnoses. It is available on CIHI’s COVID-19 resources page and the Codes and Classifications web page. It was also distributed on social media.

Slide 37: COVID-19 lab test performed: Absence of documentation

  • In this scenario, the only documentation available is “COVID-19 nasopharyngeal swab taken.” There is no documentation of COVID-19 status (neither suspected nor confirmed).
  • Lab results are not available at the time of coding.
  • The coding direction is to flag the chart and update the code assignment when the lab results are available:
    • A positive result for COVID-19 means a confirmed case.
    • A negative result for COVID-19 means a ruled-out case.

Slide 38: Contact us

  • We are here to help you. There are already a number of COVID-19–related coding questions in eQuery. Search the database on the keyword “COVID.”
  • If you do not find an answer to your question, submit a coding question and a de-identified copy of the pertinent clinical documentation for the specific case you have encountered.
  • It is important to send a copy of the clinical documentation because — as with all cases — code assignment and application of diagnosis typing depends on the physician’s clinical documentation about the specific episode of care.
  • Send questions that are not case specific or that pertain to the content we covered during the webinar to classifications@cihi.ca.

Slide 39:

  • We hope that you found today’s session helpful and we thank you for your time.