As many hospitals continue managing COVID-19 patients, six new ICD-10 codes will help facilities obtain reimbursement.1 “Hospitals were pushing for these codes. Everybody wants COVID-specific data and codes right now,” says Sue Bowman, RHIA, CCS, MJ, FAHIMA, senior director of coding policy and compliance for the American Health Information Management Association.

Before these codes, which became effective on Jan. 1, hospitals could not identify that certain conditions were caused by COVID-19. A specific code for COVID-19 (U07.1) was implemented on April 1, 2020. However, there was not a code specifically for pneumonia caused by COVID-19 or multisystem inflammatory syndrome (MIS). Before Jan. 1, 2021, if the patient developed pneumonia caused by COVID-19, hospitals would assign codes for COVID-19 and other viral pneumonia (J12.89).

“You could still identify the patient as a COVID patient from the U07.1 code, but the pneumonia code didn’t specifically indicate that the pneumonia was due to COVID,” Bowman explains.

In the case of MIS, if the patient also had current COVID-19, code U07.1 would be assigned first. The problem was that if a patient was admitted with MIS and had a history of COVID-19 before Jan. 1, 2021, the patient would not have been identified as a COVID-19-related admission. “The personal history code was not specific for COVID,” Bowman says. “It was just a general code for personal history of other infectious and parasitic diseases.”

That code did not specifically describe MIS, a serious, complex condition associated with some COVID-19 patients, both children and adults. “The new MIS code [M35.81] in particular is really going to improve hospital data. It was a very vague code before that really didn’t explain what it was,” Bowman reports.

The new code for MIS will help maximize reimbursement for these patients. Some patients with MIS no longer had COVID-19 at the time of admission. This made it harder to justify the admission and secure the appropriate reimbursement. “The MIS code explains that this is something that’s related to the previous COVID condition. Before, with the vague, nonspecific code, there was nothing to connect it to COVID,” Bowman says.

Also, some health plans follow specific reimbursement policies related to COVID-19 admissions. With the new code, hospitals can make it clear the patient with MIS falls into this group. The “personal history of COVID” code (Z86.16) allows hospitals to give more information on the patient’s overall condition. This can be used to justify the need for inpatient admission. “Even though the COVID has resolved, the code is used to explain that there is an after-effect or lingering effect,” Bowman explains.

Previously, nonspecific codes were used for patients with MIS and other COVID-19-related conditions. Staff need to understand how to use the latest codes. For example, the code for pneumonia (J12.82) caused by COVID-19 cannot be used as a principle diagnosis. “It has to be coded as secondary, with COVID [code U07.1] coded first as the principle diagnosis,” Bowman stresses.

For outpatients, the codes most likely to cause confusion are those for screening (Z11.52) vs. exposure (Z20.822). The exposure code is for everyone who is tested for COVID and the results are unknown or negative. However, if someone is known to have tested positive, then the code for COVID is used. “Official coding guidelines stipulate that during a pandemic, hospitals should not be coding any encounters for screening,” Bowman says.

Staff should use the “exposure” code instead. If someone arrives to be tested and does not report symptoms, staff might think of it as a screening. “That could create some confusion,” Bowman says.

The issue is the patient really is not “screened” when the virus remains so prevalent. The patient is tested because he or she may have been exposed to the virus. Thus, during the pandemic, the “exposure” code should be used. “The screening code is waiting in the wings until the pandemic is declared over,” Bowman says.

REFERENCE

  1. Centers for Disease Control and Prevention. New ICD-10-CM code for the 2019 novel coronavirus (COVID-19), Dec. 3, 2020.