Q&A: Capturing manifestations, complications for COVID-19 patients

Q: We have patients being admitted for novel coronavirus (COVID-19) and most of them have a laundry list of various manifestations and complications. Do all manifestations and complications need to be reported in ICD-10-CM?

A: Yes, capturing these is very important, especially since in order to fully capture the severity of illness and risk of mortality for confirmed cases of COVID-19, all manifestations and complications of the virus need to be reported by the coder.

For some background, patients infected with the virus may be asymptomatic, may experience minimal symptoms, or they may have severe respiratory failure and multiple organ failure. Mortality from COVID-19 can be related to acute respiratory distress syndrome or septic shock, but these are not the only possible complications of COVID-19. COVID-19 treatment may also lead to long-term consequences for those patients who survive.  

The virus enters the body via inhaled droplets and finds access to the replicating machinery of cells via angiotensin-converting enzyme 2, which is highly expressed in lung epithelial cells in the alveolar space, deep in the lungs. This may be why COVID-19 patients most often present with lower, rather than upper, respiratory tract infections.

The virus may leave patients susceptible to opportunistic infections by organisms such as staph aureus, so watch for documentation of bacterial pneumonia being treated in addition to COVID-19 pneumonia. The antibiotic choice will be a clue to the organism or organisms that are suspected. 

Some COVID-19 patients have been reported to experience coagulopathy and thrombosis, deep vein thrombosis, pulmonary embolism, and even stroke. If there is evidence of both bleeding and clot formation, the patient may have disseminated intravascular coagulation, a major comorbid condition that will increase the severity and risk for that patient.

Some cardiac complications that have occurred are cardiomyopathy, heart failure, cardiac arrest, and type 2 myocardial infarction (MI). Look for the characteristic rise and fall in troponin plus symptoms of ischemia, EKG findings, or imaging evidence of loss of viable myocardium to support a query for type 2 MI. 

COVID-19 patients may experience acute renal failure with or without acute tubular necrosis (ATN). Look for evidence of a 30-50% rise in creatinine with a corresponding fall in glomerular filtration rate with a slow (or no) return to baseline in the setting of hypotension or shock to support a query for ATN.

A recent AHA/AHIMA FAQ advises:

Because COVID-19 is primarily a respiratory condition, any other signs/symptoms would be coded separately unless another definitive diagnosis has been established for the other signs or symptoms. This is supported by Guideline IC.18.b, ‘Codes for signs and symptoms may be reported in addition to a related definitive diagnosis when the sign or symptom is not routinely associated with that diagnosis.’

Diarrhea, nausea, vomiting, anosmia (loss of smell), ageusia (loss of taste), and transaminitis are some of the gastrointestinal and neurological signs and symptoms that have been associated with COVID-19 and should be coded in addition to ICD-10-CM code U07.1 (COVID-19) if they are documented. Glasgow Coma Scale (GCS) scores may also be coded if this data is recorded either by emergency services personnel, nursing staff or physicians. Low GCS scores can have significant impact on severity of illness and risk of mortality.

Finally, you should not neglect to code all comorbid conditions, such as diabetes, obesity, hypertension, and other cardiovascular diseases, which may prove to be risk factors for more severe manifestations of and/or a higher rate of mortality from the virus.

There is no specific timeframe for when COVID-19 becomes “history of” for a patient. U07.1 should continue to be reported for subsequent admissions while COVID-19 is still active as evidenced by provider documentation that it is being monitored, evaluated, or treated. When the provider documents “history of COVID-19” and it is no longer being evaluated, monitored, or treated, code Z86.19 (personal history of other parasitic and infectious diseases) should be assigned.

Editor’s note: Sarah A. Nehring, CCS, CCDS, inpatient lead coder at a large teaching hospital in central Illinois, answered this question. Contact her at nehrings4@gmail.com.

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.