Q&A: Querying for COVID-19 test results

Q: If an inpatient is transferred before we receive a positive novel coronavirus (COVID-19) lab result, do we need to query the provider to amend the discharge summary to state “COVID-19 positive”?

A: Per the Coding Clinic Advisor published April 1, 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. 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 hospitals consider developing facility-specific coding guidelines to hold back coding of inpatient admissions until the test results for COVID-19 testing are available.

Editor’s note: This question was answered by Shannon McCall, RHIA, CCS, CCS-P, CPC, CEMC, CRC, CCDS, CCDS-O, director of HIM and coding for HCPro in Middleton, Massachusetts.

This answer was provided based on limited information. Be sure to review all documentation specific to your own individual scenario before determining appropriate code assignment.