TIPS for Sepsis Coding

Additional AHA Coding Clinic Clarification

Viral Sepsis (Coding Clinic, Third Quarter 2016: Page 8)

Question:

How would viral sepsis be coded in ICD-10-CM? The type of viral infection is unspecified. In ICD-9-CM, “Viral” was a sub term under septicemia, but it is not present as a sub term under sepsis in ICD-10-CM. By selecting “sepsis with specified organism NEC” code A41.89 is referenced. However, in ICD-10-CM, categories A30-A49 encompass “other bacterial diseases.” Would it be appropriate to assign a bacterial code for a viral condition?

Answer:

Assign codes A41.89, Other specified sepsis, and B97.89, Other viral agents as the cause of diseases classified elsewhere. Although codes in categories A30-A49 classify bacterial illnesses, there is no specific code for viral sepsis. “Sepsis, specified organism NEC” is indexed to code A41.89. Code A41.89 is the best available option to capture the concept of sepsis, since ICD-10-CM does not have a specific code for viral sepsis, along with code B97.89 to provide an additional level of specificity when the virus is not specified.

 

Sepsis due to Aspiration Pneumonia (Coding Clinic for ICD-10-CM/PCS, Second Quarter 2020: Page 28)

Question:

When the provider documents “sepsis due to aspiration pneumonia,” is a code for the sepsis, or the aspiration pneumonia assigned as the principal diagnosis?

Answer:

Assign code A41.9, Sepsis, unspecified organism, as the principal diagnosis. Codes J18.9, Pneumonia, unspecified organism, and J69.0, Pneumonitis due to inhalation of food and vomit, should be assigned as additional diagnoses. Sepsis indicates infection and the body’s response to it. Aspiration pneumonia may be just from the direct effect of inhaled material, such as a chemical effect, or it may involve infection; however, for sepsis to result, it would need to involve an infectious pneumonia. Therefore, codes J18.9 and J69.0 are both needed to show the presence of a localized infection (pneumonia and unspecified organism) as well as pneumonia due to aspiration. When sepsis and aspiration pneumonia are related (i.e., sepsis due to aspiration pneumonia or sepsis related to aspiration pneumonia) and present on admission, sepsis should be sequenced as the principal diagnosis.

 

Tips and Reminders:

• Always read the full ICD-10-CM chapter-specific coding guidelines for sepsis in chapters 1 and 15 (if applicable).
• Always read any coding instructions under the diagnosis codes for “code-first” and “use additional” code notes.
• Review any pertinent AHA Coding Clinic(s) that pertain to sepsis.

 

 

References:

ICD-10-CM Chapters 1 and 15 2023 ICD-10-CM Documentation Guidelines

Coding Clinic for ICD-10-CM/PCS, First Quarter 2018: Page 16

Coding Clinic, Third Quarter 2016: Page 8

Sepsis Vs. Severe Sepsis Vs. Septic Shock

 

How to Code Sepsis, Severe Sepsis, and Septic shock

Introduction:

Sepsis is a potentially life-threatening complication of an infection and occurs when chemicals released in the bloodstream to fight the infection trigger inflammatory responses throughout the body. This inflammation can trigger a cascade of changes that damage multiple organ systems, causing them to fail. While the coding for sepsis can be particularly challenging, fortunately, we have the ICD-10-CM Official Guidelines for Coding and Reporting to use as a guide.

Chapter 1 of the ICD-10-CM guidelines provides incredibly detailed instruction on coding for sepsis, severe sepsis, and septic shock infections. The guidelines instruct to first assign the appropriate code for the underlying systemic infection. If the type of infection is not specified, then report code A41.9, Sepsis, unspecified organism. R65.20 (severe sepsis without septic shock) or R65.21 (severe sepsis with septic shock) should only be assigned if severe sepsis is specified when an associated acute organ dysfunction is documented.

 

Example: Sepsis Coding

An 85-year-old male is admitted with sepsis.

1. 1. A41.9 – Sepsis, unspecified organism

Note, only code A41.9, Sepsis, unspecified organism since only sepsis is documented and the type of infection is not specified; but what would you code if the provider documents “85-year-old male is admitted with urosepsis?”

You would not be able to assign a diagnosis code. Instead, you need to query the provider for clarification. The guidelines state, “The term urosepsis is a nonspecific term. It is not to be considered synonymous with sepsis. It has no default code in the Alphabetic Index. Should a provider use this term, he/she must be queried for clarification.”

 

Severe Sepsis

To accurately assign codes for severe sepsis, refer to sections 1.C.1.d.1.b and 1.C.1.d.3 of the ICD-10-CM Chapter 1 Guidelines which states a minimum of two codes is needed to accurately code for severe sepsis. The first code is for the underlying systemic infection. Once again, if the underlying infection is not specified, report A41.9, Sepsis, unspecified. Next, report a code from subcategory R65.20, severe sepsis without septic shock or R65.21 severe sepsis with septic shock. Then, report the additional code(s) for the associated acute organ dysfunction. Remember, when reporting R65.20 or R65.21 an associated organ dysfunction must be documented.

 

Example: Severe Sepsis Coding

A 41-year-old female is admitted with sepsis that has caused hypoxic, acute respiratory failure.

1. 1. A41.9 – Sepsis, unspecified organism
   2. R65.20 – Severe sepsis without septic shock
   3. J96.01 – Acute respiratory failure with hypoxia

First, code the underlying systemic infection (A41.9, Sepsis, unspecified organism).  Second, code the severe sepsis as the patient has an acute organ failure associated with the sepsis (R65.20 – severe sepsis without septic shock). Third, code the acute organ dysfunction (J96.01- hypoxic, acute respiratory failure).

 

Septic Shock

The ICD-10-CM Chapter 1 Guidelines state that septic shock refers to circulatory failure associated with severe sepsis. The guidelines instruct to first code the systemic infection, followed by R65.21, severe sepsis with septic shock. However, if the septic shock is postprocedural, code T81.12, postprocedural septic shock.  Note the instructions in the Tabular state septic shock cannot be assigned as a principal diagnosis.

 

Sepsis or Severe Sepsis with a Localized Infection

If the reason for admission is sepsis or severe sepsis with a localized infection, such as pneumonia, the Guidelines instruct to code the underlying infection as the first diagnosis if the type of infection is not specified assign code A41.9, Sepsis, unspecified. The code for the localized infection should be coded second.  If the patient has severe sepsis with a localized infection, report a code from subcategory R65.20 as a secondary diagnosis.  However, if the patient is admitted with a localized infection but does not develop sepsis until after the admission, code the localized infection followed by the sepsis/severe sepsis codes.

 

Example 1: Severe sepsis with localized infection coding

A 41-year-old female is admitted with sepsis with pneumonia that has caused hypoxic, acute respiratory failure.

1. 1. A41.9 – Sepsis, unspecified organism
   2. R65.20 – Severe sepsis without septic shock
   3. J96.01 – Acute respiratory failure with hypoxia
   4. J18.9 – Pneumonia, unspecified organism

Assign the underlying systemic infection as the primary diagnosis (A41.9, Sepsis, unspecified organism). Since the patient has an acute organ failure associated with the sepsis, assign R65.20, severe sepsis without septic shock as the second diagnosis. Note, the presence of shock was not documented. Code the acute organ dysfunction (J96.01 – hypoxic, acute respiratory failure) as the third diagnosis with the localized infection (J18.9 – pneumonia) coded as the fourth diagnosis.

 

Example 2: Severe sepsis with localized infection coding

A 41-year-old female is admitted with urosepsis caused by an Escherichia coli UTI that has caused hypoxic, acute respiratory failure. Diagnosis codes for this example:

1. 1. A41.51 – Sepsis due to Escherichia coli [E. coli]
   2. R65.20 – Severe sepsis without septic shock
   3. J96.01 – Acute respiratory failure with hypoxia
   4. N39.0 – Urinary tract infection, site not specified

First, assign code A41.51, sepsis due to Escherichia coli [E. coli] for the underlying systemic infection. Since the patient has an acute organ failure associated with the sepsis, assign R65.20, severe sepsis without septic shock as the second diagnosis. Note, the presence of shock was not documented. Then, assign J96.01, hypoxic, acute respiratory failure for the organ failure as the third diagnosis and code N39.0, urinary tract infection, site not specified for the local infection as the fourth diagnosis.

You may be wondering why we would not code B96.20, Unspecified Escherichia coli [E. coli] since there is a “use additional code” note under code N39.0 in the Tabular.  See the question and answer below from Coding Clinic for ICD-10-CM/PCS, First Quarter 2018, page 16:

Question:

A patient with mental status change is admitted and after diagnostic studies, the provider diagnosed sepsis due to Escherichia coli (E. coli) urinary tract infection (UTI). What are the appropriate code assignments for this diagnostic statement? There is confusion among coding professionals regarding the application of the instructional note stating: “Use additional code (B95-B97), to identify infectious agent” at code N39.0, Urinary tract infection, site not specified, versus assigning a code that identifies both sepsis and the infectious agent.

Answer:

Assign code A41.51, Sepsis due to Escherichia coli [E. coli], and code N39.0, Urinary tract infection, site not specified, for the UTI.

Do not assign code B96.20, Unspecified Escherichia coli [E. coli] as the cause of diseases classified elsewhere, as an additional diagnosis. Code A41.51 clearly identifies the causal bacterium for both the sepsis and the UTI. Assigning B96.20 as an additional code is redundant.”

 

Sepsis Due to a Postprocedural Infection

Several questions must be answered before coding sepsis due to a post-procedural infection.

1. Was the procedure obstetrical?
2. Is the site of the infection documented?
3. Is the infectious agent documented?
4. Is severe sepsis or acute organ dysfunction documented?

If it is known that the procedure was non-obstetrical and the site of the infection is documented, assign a code from T81.40-T81.43 as our primary code. Then, code T81.44, Sepsis following a procedure, as the second code. For the third diagnosis, code the underlying infection, or A41.9, if the type of infection is not documented.  If the documentation stated severe sepsis or if there was a sepsis-associated acute organ dysfunction, code R65.20, along with the code for the organ dysfunction.

If the procedure was obstetrical and the site of the infection is documented, assign a code from O86.00-O86.03 as the primary code. Then, code O86.04, Sepsis following an obstetric procedure as the second code. For the third diagnosis, code the underlying infection or A41.9 if the type of infection is not documented. If the documentation stated severe sepsis or if there was a sepsis associated acute organ dysfunction, code R65.20 along with the code for the organ dysfunction.

For infections following infusion, transfusion, therapeutic injection, or immunization, assign a code from subcategory T80.2, Infections following infusion, transfusion, and therapeutic injection, or code T88.0-, Infection following immunization. Then assign a code for the specific infection. If severe sepsis is documented, assign the appropriate code from subcategory R65.2 along with the additional codes(s) for any acute organ dysfunction.

 

Example: Sepsis due to a postprocedural infection coding

A 52-year-old male is admitted with sepsis due to a post-operative infection of the small intestine, following an appendectomy.

1. 1. T81.43XA – Infection following a procedure, organ, and space surgical site, initial encounter
   2. T81.44XA – Sepsis following a procedure, initial encounter
   3. A41.9 – Sepsis, unspecified organism

Assign T81.43XA, infection following a procedure, organ and space surgical site, initial encounter as the first diagnosis, this is the site of the infection. Then, assign code T81.44XA, Sepsis following a procedure, initial encounter as our second diagnosis. Finally, code A41.9, Sepsis unspecified organism as the third diagnosis.

 

Postprocedural Infection and Postprocedural Septic Shock

If a post-procedural infection results in septic shock, the ICD-10-CM Chapter 1 Guidelines instructs to first code the sepsis due to postprocedural infection (see codes above), followed by code T81.12-, Postprocedural septic shock.  The guidelines state not to assign code R65.21, Severe sepsis with septic shock. Additional code(s) should be assigned for any acute organ dysfunction.

 

Example: Postprocedural infection and postprocedural septic shock coding

A 52-year-old male is admitted with septic shock due to a post-operative infection of the small intestine following an appendectomy that has caused acute liver failure.

1. 1. T81.43XA – Infection following a procedure, organ, and space surgical site, initial encounter
   2. T81.44XA – Sepsis following a procedure, initial encounter
   3. A41.9 – Sepsis, unspecified organism
   4. T81.12XA – Postprocedural septic shock, initial encounter
   5. K72.00 – Acute and subacute hepatic failure without coma

Frist, assign the site of the infection as the first diagnosis T81.43XA – Infection following a procedure, organ and space surgical site, initial encounter. Next, assign T41.44XA for sepsis following a procedure (Sepsis following a procedure, initial encounter). Code A41.9, Sepsis, unspecified organism as the third diagnosis, per the instructions under diagnosis T81.44- that state to use an additional code to identify the sepsis. The fourth diagnosis code is T81.12XA, Postprocedural septic shock, initial encounter. The fifth and final code is K72.00, Acute and subacute hepatic failure without coma, for the acute organ dysfunction.

 

Sepsis and Severe Sepsis Associated with a Noninfectious Process (condition)

Per ICD-10-CM Chapter 1 Guideline I.C.1.d.6., “In some cases, a noninfectious process (condition) such as trauma, may lead to an infection which can result in sepsis or severe sepsis. If sepsis or severe sepsis is documented as associated with a noninfectious condition, such as a burn or serious injury, and this condition meets the definition for principal diagnosis, the code for the noninfectious condition should be sequenced first, followed by the code for the resulting infection. If severe sepsis is present, a code from subcategory R65.2 should also be assigned with any associated organ dysfunction(s) codes. It is not necessary to assign a code from subcategory R65.1, Systemic inflammatory response syndrome (SIRS) of non-infectious origin, for these cases.

If the infection meets the definition of principal diagnosis, it should be sequenced before the non-infectious condition. When both the associated non-infectious condition and the infection meet the definition of principal diagnosis, either may be assigned as principal diagnosis.

Only one code from category R65, Symptoms and signs specifically associated with systemic inflammation and infection, should be assigned. Therefore, when a non-infectious condition leads to an infection resulting in severe sepsis, assign the appropriate code from subcategory R65.2, Severe sepsis. Do not additionally assign a code from subcategory R65.1, Systemic inflammatory response syndrome (SIRS) of non-infectious origin.”

 

Example: Sepsis and severe sepsis associated with a noninfectious process (condition) coding

A 68-year-old female is admitted with a traumatic subdural hematoma and developed sepsis with acute kidney failure 3 days after the admission.

1. 1. S06.5XAA – Traumatic subdural hemorrhage with loss of consciousness status unknown, initial encounter
   2. A41.9 – Sepsis, unspecified organism
   3. R65.20 – Severe sepsis without septic shock
   4. N17.9 – Acute kidney failure, unspecified

We would assign S06.5XAA, Traumatic subdural hemorrhage with loss of consciousness status unknown, initial encounter as the primary diagnosis, because the patient was admitted for a noninfectious condition. We would code A41.9 as the second diagnosis because the sepsis did not occur until three days after the admission. We would code the R65.20 as the third diagnosis because there was an acute organ dysfunction associated with the sepsis Finally, we would code N17.9, Acute kidney failure, unspecified as the fourth diagnosis.

 

Additional Sepsis Guidelines from Chapter 15

Not all sepsis related guidelines are found in chapter 1. Chapter 15 also discusses sepsis coding.

 

Sepsis and Septic Shock Complicating Abortion, Pregnancy, Childbirth, and the Puerperium

The sepsis coding guideline in Chapter 15(I.C.15.j) is like those in chapter 1.  We would assign the code for sepsis complicating abortion, pregnancy, childbirth, and the puerperium as our primary code.  Then we would code the specific type of infection or A41.9 if the type is not documented as our second diagnosis.  After that we would code R65.2, Severe sepsis if severe sepsis (or an acute organ dysfunction associated with sepsis) is documented. Then we would code the associated acute organ dysfunction.

 

Example: Sepsis and septic shock complicating abortion, pregnancy, childbirth, and the puerperium coding

A 24-year-old female presents with sepsis due to an intraabdominal abscess that developed 3 days after a scheduled C-section. Diagnosis codes for this example:

1. 1. O86.03 – Infection of obstetric surgical wound, organ, and space site
   2. O86.04 – Sepsis following an obstetrical procedure
   3. A41.9 – Sepsis, unspecified organism

Assign the site of the infection as the first diagnosis (Infection of obstetric surgical wound, organ, and space site – O86.03). Then, assign the additional code for sepsis following a procedure (Sepsis following an obstetrical procedure – O86.04). Per the instructions under diagnosis O86.04, use an additional code to identify the sepsis (Sepsis, unspecified organism – A41.9).

 

Puerperal Sepsis

Per ICD-10-CM Chapter 15 guideline I.C.15.k. Code O85, Puerperal sepsis, should be assigned with a secondary code to identify the causal organism (e.g., for a bacterial infection, assign a code from category B95-B96, Bacterial infections in conditions classified elsewhere). A code from category A40, Streptococcal sepsis, or A41, Other sepsis, should not be used for puerperal sepsis. If applicable, use additional codes to identify severe sepsis (R65.2-) and any associated acute organ dysfunction.

Code O85 should not be assigned for sepsis following an obstetrical procedure (See Section I.C.1.d.5.b., Sepsis due to a postprocedural infection).

 

Example: Puerperal sepsis coding

A 31-year-old female was admitted with postpartum sepsis (7 days postpartum) with associated respiratory failure.

1. 1. O85 – Puerperal sepsis
   2. R65.20 – Severe sepsis without septic shock
   3. J96.00 – Acute respiratory failure, unspecified whether with hypoxia or hypercapnia

Following the Chapter 15 ICD-10-CM Guideline above for puerperal sepsis, assign O85Puerperal sepsis as the first diagnosis. Note, there was no causal organism identified but since the patient has acute organ dysfunction, assign R65.20, Severe sepsis as the second diagnosis. Code J96.00, Acute respiratory failure, unspecified whether hypoxia or hypercapnia as the third diagnosis to identify the acute organ dysfunction.

The key to successfully coding sepsis lies in keeping a copy of the ICD-10-CM Guidelines on hand.  You can find these guidelines in the front of your ICD-10-CM codebook. To download a PDF version of the 2023 Guidelines, click here.

 

Sample ABLA Query Form

Acute Blood Loss Anemia Query Template

Sample ABLA query form

Documentation in the medical record indicates the following:  

• Diagnosis of Anemia [include type]  
• Drop in Hct/Hgb from______ to____
• Blood transfusion of xxx units  
• GI Bleeding [or other hemorrhage]  
• Other:

Based on your medical judgment, can you further clarify in the progress notes the diagnosis
associated with these findings such as: 

• Acute blood loss anemia  
• Acute hemorrhagic anemia  
• Chronic blood loss anemia  
• Acute on chronic blood loss anemia  
• Iron deficiency anemia  
• Other anemia: (please specify)  
• None of the above / Not applicable

In responding to this request, please exercise your independent professional judgment. The 
fact that a question is asked does not imply that any particular diagnosis is desired or
expected.

Thank you!

Palliative Care Z51.5

Palliative Care

Z51.5 Encounter for Palliative Care Reporting

It is essential when the treating provider documents the patient is receiving palliative care that the coding abstract reflects the assignment of code Z51.5 Encounter for palliative care. This code should be reported within one of the first 8 secondary diagnosis fields to ensure it is reported on the UB-04. There are several statistics gathered for healthcare organizations regarding outcomes and mortality for public reporting. The coding data needs to accurately reflect our patient population for these measures. Included in this alert are resources from Coding Clinic to provide guidance for accurate reporting. If at any time you have a question regarding the appropriate reporting of any diagnosis or procedure please contact your supervisor prior to finalizing the coding abstract for an encounter. 

**Coding Clinic Guidance for Palliative Care Reporting**

Palliative care is an alternative to aggressive treatment for patients who are in the terminal phase of an illness. Care is focused on the management of pain and other symptoms of the disease, which is often more appropriate than aggressive care when a patient is dying of an incurable illness. Code Z51.5 Encounter for palliative care, is used to classify admissions or encounters for comfort care, end-of-life care, hospice care, and terminal care for terminally ill patients. It may be used in any health care setting.

Common terminology providers may use to reference palliative care:  

• Hospice Care  

• End-Of-Life Care 

• Comfort Care  

• Palliative Care  

• Comfort Measures Only (CMO) 

When to use Z00.6?

 When to use code Z00.6 in coding

MEDICARE ACCOUNTS ONLY: Diagnosis code Z00.6 must be in the 2^nd diagnosis code position

 

• ·         Carotid Artery Stenting/Angioplasty (Gore Grafts Only)

• ·         ICD’s-Implantable Cardioverter Defibrillators

• ·         Impella Heart Assistance Device

• ·         Leaders Free II-Bio Freedom Pivotal Study (Bare Metal Stents)

• ·         Pacemaker, Micra Leadless

• ·         TAVR-Transcatheter Aortic Valve Replacement

• ·         TMVR-Transcatheter Mitral Valve Replacement

• ·         Watchman’s Procedure (LAA) Left Atrial Appendage

• ·         Mitral Clips (Mitral Valve Repairs)

• ·         EP Studies

Query-Unable to determine

 Query response unable to determine

• ·         When querying for greater specificity of a documented diagnosis, a provider’s response of “unable to determine” would not preclude the coding of the documented diagnosis. The “unable to determine” response would just not allow assignment of a more specific code.

Example: a provider query requests clarification of the type and/or severity of documented congestive heart failure (CHF). If the provider responds “unable to determine”, the CHF diagnosis code would be reported, but the additional specificity would not be able to be represented in the reported code.

• ·         When querying for clinical indicators without a definitive relationship to an underlying diagnosis, a provider’s response of “unable to determine” would preclude the coding of any of the proposed definitive diagnosis(s) options included on the query template. The coder would only assign codes for the signs or symptoms (following ICD-10-CM Official Coding Guidelines) which prompted the query.

• ·         When querying for clarification of whether a diagnosis or condition has been ruled in or ruled out, a provider’s response of “unable to determine” would indicate uncertainty. Coding would follow the ICD-10-CM Official Coding Guidelines for coding “Uncertain Diagnosis.”

ICD-10-CM Official Coding Guidelines - H. Uncertain Diagnosis; If the diagnosis documented at the time of discharge is qualified as “probable”, “suspected”, “likely”, “questionable”, “possible”, or “still to be ruled out”, or other similar terms indicating uncertainty, code the condition as if it existed or was established. The bases for these guidelines are the diagnostic workup, arrangements for further workup or observation, and initial therapeutic approach that correspond most closely with the established diagnosis.

ICD-10-CM Covid 19 FAQs - PART 2

 ICD-10-CM Questions

11. 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.

 

12. Question: How should we handle cases related to COVID-19 when the test results aren’t back yet? The supplementary guidance and FAQs are confusing since some times COVID-19 is not “ruled out” during the encounter, since the test results aren’t back yet. (3/24/2020)

Answer: Due to the heightened need to capture accurate data on positive COVID-19 cases, 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. This advice is limited to cases related to COVID-19.

 

13. 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 seeing in our emergency department and if results are not available at the time of discharge, we are reluctant to query the physicians to go 5 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 COVID-19 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[1]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.

 

14. Question: We are unsure about how to interpret the newly released COVID-19 guidelines in relation to the uncertain diagnosis guideline which refers to diagnoses “documented at the time of discharge” stated as possible, probable, etc. Can we code these cases as confirmed COVID-19 if the test results don’t come back until a few days later and the patient has already been discharged? (4/1/2020)

Answer: Yes, if a test is performed during the visit or hospitalization, but results come back after discharge positive for COVID-19, then it should be coded as confirmed COVID-19.

 

15. Question: Since the new guidelines for COVID regarding sepsis just say to refer to the sepsis guideline, is that then saying that sepsis would be sequenced first and then U07.1 for a patient presenting with sepsis due to COVID-19? (4/1/2020; revised 12/11/2020)

Answer: Whether or not sepsis or U07.1 is assigned as the principal diagnosis depends on the circumstances of admission and whether sepsis meets the definition of principal diagnosis. For example, if a patient is admitted with pneumonia due to COVID-19 which then progresses to viral sepsis (not present on admission), the principal diagnosis is U07.1, COVID-19, followed by the codes for the viral sepsis and viral pneumonia. On the other hand, if a patient is admitted with sepsis due to COVID-19 pneumonia and the sepsis meets the definition of principal diagnosis, then the code for viral sepsis (A41.89) should be assigned as principal diagnosis followed by codes U07.1 and the appropriate viral pneumonia code (code J12.89, 6 Other viral pneumonia, for discharges/encounters prior to January 1, 2021 or code J12.82, Pneumonia due to coronavirus disease 2019, for discharges/encounters after January 1, 2021) as secondary diagnoses.

 

16. Question: Please provide guidance on correct coding when the provider has documented COVID-19 as a definitive diagnosis before the test results are available, and the test results come back negative. (4/16/2020)

Answer: Coding professionals should query the provider if the provider documented COVID-19 before the test results were back and the test results come back negative. Providers should be given the opportunity to reconsider the diagnosis based on the new information.

 

17. Question: Please provide guidance on correct coding when the provider has confirmed the documented COVID-19 after the test results come back negative. How should this be coded? (4/16/2020)

Answer: If the provider still documents and confirms COVID-19 even though the test results are negative, or if the provider documented disagreement with the test results, assign code U07.1, COVID-19. As stated in the ICD-10-CM Official Guidelines for Coding and Reporting for COVID-19, “Code only a confirmed diagnosis of the 2019 novel coronavirus disease (COVID-19) as documented by the provider . . . the provider’s documentation that the individual has COVID-19 is sufficient.”

 

18. Question: When a patient who previously had COVID-19 is seen for a follow-up exam and the COVID-19 test is negative, what is the best code(s) to capture this scenario? (4/16/2020; revised 12/11/2020)

Answer: Assign codes Z09, Encounter for follow-up examination after completed treatment for conditions other than malignant neoplasm, and the appropriate personal history code (code Z86.19, Personal history of other infectious and parasitic diseases, for encounters prior to January 1, 2021, or code Z86.16, Personal history of COVID-19, for encounters after January 1, 2021).

 

19. Question: How should an encounter for COVID-19 antibody testing be coded? (4/28/2020)

Answer: For an encounter for antibody testing that is not being performed to confirm a current COVID-19 infection, nor is being performed as a follow-up test after resolution of COVID-19, assign Z01.84, Encounter for antibody response examination.

ICD-10-CM Covid 19 FAQs - PART 1

ICD-10-CM Questions

1. Question: What is the ICD-10-CM code for COVID-19? (revised 4/1/2020, 12/11/2020)

Answer: ICD-10-CM code U07.1, COVID-19, may be used for discharges/dates of

service on or after April 1, 2020. For more information on this code, click here. The

code was developed by the World Health Organization (WHO) and is intended to be

sequenced first followed by the appropriate codes for associated manifestations

when COVID-19 meets the definition of principal or first-listed diagnosis. See the

ICD-10-CM Official Guidelines for Coding and Reporting available on the Centers for

Disease Control and Prevention’s National Center for Health Statistics web site for

specific guidelines on usage of this code. For guidance prior to April 1, 2020, please

refer to the supplement to the ICD-10-CM Official Guidelines for coding encounters

related to the COVID-19 coronavirus outbreak.

 

2. Question: Is the new ICD-10-CM code U07.1, COVID-19, a secondary code?

(4/1/2020; revised 12/11/2020)

Answer: When COVID-19 meets the definition of principal or first-listed diagnosis,

code U07.1, COVID-19, should be sequenced first, and followed by the appropriate

codes for associated manifestations, except when another guideline requires that

certain codes be sequenced first, such as obstetrics, sepsis, or transplant

complications. However, if COVID-19 does not meet the definition of principal or

first-listed diagnosis (e.g. when it develops after admission), then code U07.1 should

be used as a secondary diagnosis.

 

3. Question: Are there additional new codes to identify other situations specific to COVID19? For example, codes for exposure to COVID-19, or observation for suspected

COVID-19 but where the tests are negative? (3/20/2020; revised 12/11/2020)

Answer: The Centers for Disease Control and Prevention’s National Center for

Health Statistics, the US agency responsible for maintaining ICD-10-CM in the US,

is implementing several new ICD-10-CM codes pertaining to COVID-19 on January

1, 2021. See ICD-10-CM FAQ #44 for further details.

 

4. Question: We have been told that the World Health Organization (WHO) has approved

an emergency ICD-10 code of “U07.2 COVID-19, virus not identified.” Is code U07.2 to

be implemented in the US too? (3/26/2020)

Answer: The HIPAA code set standard for diagnosis coding in the US is ICD-10-

CM, not ICD-10. As shown in the April 1, 2020 Addenda on the CDC website, the

only new code being implemented in the US for COVID-19 is U07.1.

 

5. Question: How should we code cases related to COVID-19 prior to April 1, 2020, the

effective date of ICD-10-CM code U07.1, COVID-19? (4/1/2020)

Answer: Please refer to the supplement to the ICD-10-CM Official Guidelines for

coding encounters related to the COVID-19 coronavirus outbreak. After April 1,

2020, refer to the ICD-10-CM Official Guidelines for Coding and Reporting available

on the Centers for Disease Control and Prevention’s National Center for Health

Statistics web site.

 

6. Question: Is the ICD-10-CM code U07.1, COVID-19 retroactive to cases diagnosed

before the April 1, 2020 date? (3/20/2020)

Answer: No, the code is not retroactive. Please refer to the supplement to the ICD10-CM Official Guidelines for coding encounters related to the COVID-19

coronavirus outbreak for guidance for coding of discharges/services provided before

April 1, 2020.

 

7. Question: Is code B97.29, Other coronavirus as the cause of diseases classified

elsewhere, limited to the COVID-19 virus? (3/20/2020)

Answer: No, code B97.29 is not exclusive to the SARS-CoV-2/2019-nCoV virus

responsible for the COVID-19 pandemic. The code does not distinguish the more

than 30 varieties of coronaviruses, some of which are responsible for the common

cold. Due to the heightened need to uniquely identify COVID-19 until the

unique ICD-10-CM code is effective April 1, providers are urged to consider

developing facility-specific coding guidelines that limit the assignment of code

B97.29 to confirmed COVID-19 cases and preclude the assignment of codes

for any other coronaviruses.

 

8. Question: What is the difference between ICD-10-CM codes B34.2 vs. B97.29?

(3/20/2020)

Answer: Diagnosis code B34.2, Coronavirus infection, unspecified, would generally

not be appropriate for the COVID-19, because the cases have universally been

respiratory in nature, so the site of infection would not be “unspecified.” Code

B97.29, Other coronavirus as the cause of diseases classified elsewhere, has been

designated as interim code to report confirmed cases of COVID-19. Please refer to

the supplement to the ICD-10-CM Official Guidelines for coding encounters related

to the COVID-19 coronavirus outbreak for additional information. Because code

B97.29 is not exclusive to the SARS-CoV-2/2019-nCoV virus responsible for

the COVID-19 pandemic, we are urging providers to consider developing

facility-specific coding guidelines that limit the assignment of code B97.29 to

confirmed COVID-19 cases and preclude the assignment of codes for any

other coronaviruses.

 

9. Question: Does the supplement to the ICD-10-CM Official Guidelines for coding

encounters related to the COVID-19 coronavirus outbreak apply to all patient encounter

types, i.e., inpatient and outpatient, specifically in relation to the coding of “suspected”,

“possible” or “probable” COVID-19? (3/20/2020)

Answer: Yes, the supplement applies to all patient types. As stated in the

supplement guidelines, “If the provider documents “suspected”, “possible” or

“probable” COVID-19, do not assign code B97.29. Assign a code(s) explaining the

reason for encounter (such as fever, or Z20.828, Contact with and (suspected)

exposure to other viral and communicable diseases).”

 

 

10. Question: The supplement to the ICD-10-CM Official Guidelines for coding encounters

related to the COVID-19 coronavirus outbreak refers to coding confirmed cases in a

couple of instances, but it does not specify what “confirmation” means similar to

language in guidelines found for reporting of HIV, Zika and H1N1. Can you clarify

whether the record needs to have a copy of the lab results or what lab tests are

approved for confirmation? (3/20/2020)

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.