Lots of folks are making statements about physician documentation linking positive test results and not being able to code based on lab results. When coding COVID 19, there are exceptions in both cases.
Code only confirmed cases. 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.
AHIMA and AHA FAQ: ICD-10-CM coding for COVID-19 (updated Apr 17)
Question: Should presumptive positive COVID-19 test results be coded as confirmed? (3/24/2020) Answer: Yes, 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 the COVID-19 virus is no longer required.
Answer: The intent of the guideline is to code only confirmed cases of COVID-19. It is not required that a copy of the confirmatory test be available in the record or documentation of the test result. The provider’s diagnostic statement that the patient has the condition would suffice.
Question: Based on the recently released guidelines for COVID-19 infections, does a provider need to explicitly link the results of the COVID-19 test to the respiratory condition as the cause of the respiratory illness to code it as a confirmed diagnosis of COVID-19? Patients are being seen in our emergency department and if results are not available at the time of discharge, we are reluctant to query the physicians to go back and document the linkage when the results come back several days later. (4/1/2020)
Answer: No, the provider does not need to explicitly link the test result to the respiratory condition, the positive test results can be coded as confirmed COVID-19 cases as long as the test result itself is part of the medical record. As stated in the coding guidelines for COVID19 infections that went into effect on April 1, code U07.1 may be assigned based on results of a positive test as well as when COVID-19 is documented by the provider. Please note that this advice is limited to cases related to COVID-19 and not the coding of other laboratory tests. Due to the heightened need to uniquely identify COVID-19 patients, we recommend that providers consider developing facility-specific coding guidelines to hold back coding of inpatient admissions and outpatient encounters until the test results for COVID-19 testing are available.
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About the author
Lisa Selman-Holman, JD, BSN, RN | President, Selman-Holman, a Briggs Healthcare Company
Lisa has done it all in health care, from being an entry-level nurse to home care executive, and now, national educator and consultant for home health and skilled nursing. She puts her more than 30 years experience into many projects, including editing the only home-health specific coding manual and working one-on-one with home health agencies and skilled nursing facilities through audit and operations reviews.
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