Key considerations for revenue cycle teams to optimize coding and maximize revenue during COVID-19

• A new code for COVID-19 discharges offers a 20% bump in the assigned MS-DRG payment from CMS.
• Clinicians should know that a positive test result is not required to establish a COVID-19 diagnosis for coding purposes.
• If a patient admitted with a respiratory diagnosis then tests positive for COVID-19, coders can link the result to the respiratory illness.

With new legislation such as the Coronavirus Aid, Relief and Economic Security (CARES) Act supplying grants to help stabilize hospitals and health systems, documentation and coding become increasingly vital for providers to capture the available funding.

An unprecedented off-cycle adoption of code U07.1, COVID-19, effective with discharges on and after April 1, 2020, was announced by the Centers for Disease Control and Prevention in mid-March.

 As provided in the ICD-10-CM Official Guidelines for Coding and Reporting, the coding guidance for COVID-19 has unique features that all coding professionals and clinical documentation specialists need to understand. The guidance was approved by the cooperating parties: American Health Information Management Association, American Hospital Association, CMS and the National Center for Health Statistics.

It is notable that per the CARES Act, for patients discharged while the COVID-19 Public Health Emergency is in effect, the presence of code U07.1, COVID-19 results in a 20% increase in the assigned MS-DRG payment from CMS.

Key points for coding professionals, clinical documentation specialists and providers

The most important message to convey to clinicians is that a clinical diagnosis of COVID-19 infection establishes the diagnosis; a positive test is not required. If the clinical picture and treatment of the patient support a COVID-19 diagnosis, the physician’s diagnostic statement that the patient has the condition is sufficient, as noted in an FAQ from the American Hospital Association and American Health Information Management Association.

Clinicians should avoid using terms that reflect an uncertain diagnosis of COVID-19, such as probable or suspected, when they believe clinically that the patient has the infection.

Other key points about COVID-19 coding include:

Test results. When a test is positive for a patient admitted with a respiratory diagnosis, coding professionals are permitted to link the positive COVID-19 test to the respiratory illness. Explicit provider documentation of this linkage is not required for U07.1 assignment as the principal diagnosis. This guidance is in place to relieve clinicians from excessive coding queries.

Additionally, the official guidance allows COVID-19 to be coded based solely on a positive test if the test result is maintained as part of the patient’s health record. Although clinical affirmation is not required for U07.1 assignment when the COVID-19 test result is positive, documentation must link a non-pulmonary diagnosis as a manifestation of the COVID-19 infection in order to assign U07.1 as the principal diagnosis.

When test results are pending at the time of discharge, health systems may choose to adopt facility-specific guidelines to delay final coding and billing until the result is available.

Impact on claims data. Claims data will be an important source of information to enhance future preparedness should COVID-19 return or another pandemic occur. Therefore, it is important to capture codes that relate to COVID-19 exposure and screening. Z codes that reflect factors influencing health status and contact with health services, as outlined below, should be assigned when applicable.

Z03.818: Encounter for observation for suspected exposure to other biological agents ruled out. Apply when an asymptomatic patient has concerns about possible exposure, but exposure is ruled out after consultation with the provider. Although unlikely at this time given testing limitations, this code is also appropriate if an asymptomatic patient is concerned about possible exposure and tests negative. Since official guidelines indicate Z03 should be used only as a principal or first-listed diagnosis, this code rarely will be assigned to an inpatient admission.

Z20.828: Contact with and (suspected) exposure to other viral communicable diseases. Report when the provider believes the patient has experienced an actual or suspected exposure. The suspicion may be based on the fact that COVID-19 is present in the community. Patients with suspected or confirmed exposure will likely be tested. This code is applicable for symptomatic or asymptomatic patients, provided the COVID-19 test is negative or the result is unknown.

Z11.59: Encounter for screening for other viral diseases. Use for screening purposes only, meaning the patient has no symptoms and no suspected exposure. Again, given current testing limitations, this code is unlikely to be assigned with exception of specific situations such as protocols for preoperative screening.

As a public health precaution, this code likely will be used more frequently when asymptomatic people without a history of exposure begin to reenter the workforce. If a screening test returns positive, the Z code should not be assigned. Per Medicare code edits, Z11.59 is not an accepted principal diagnosis and should always be coded as a secondary diagnosis.

Disaster Related (DR) condition code. Use on claims for COVID-19-related services, including when diagnosis code U07.1, Z03.818 or Z20.828 is assigned, as per guidance from the National Uniform Billing Committee.