COVID-19 Clinical Documentation Integrity and Coding Updates: Part 2

By Andrew B. Maigur, MD, Physician Advisor Program system director, Premier Health

Since I last wrote an article on this topic almost a year ago, a lot has become clearer and more well-defined with respect to treatment guidelines as well as Clinical Documentation Integrity (CDI) and coding on COVID–19 patients.

The reimbursement implications are closely linked with accurate clinical documentation integrity and coding. Centers for Medicare & Medicaid Services (CMS) has clearly stated, "claims coded with U07.1 (code for an acute COVID-19 infection), during the admission or within 14 days prior to the admission documented in the medical record to receive the 20 percent DRG reimbursement increase as of September 1, 2020." Further guidance stated, "CMS will conduct post-payment audits to confirm the presence of a positive COVID–19 laboratory test and recoup the 20 percent increase if no such test is contained in the medical record. Code UO7.1 should be assigned when the diagnosis meets the OCG definition of COVID-19; however, if the record does not have evidence of a positive test result, hospitals can decline the additional payment at the time of claim submission to avoid the repayment." This underscores the importance of documenting the positive COVID-19 test along with the accurate date and when performed outside the hospital obtaining a copy of the laboratory test (coding team obtains via EPIC Care Everywhere).

This leads us to the next important question, "What is considered an active COVID-19 infection and is there a time limit?" The CDC states, "available data indicate that persons with mild to moderate COVID–19 remain infectious no longer than 10 days after symptom onset. Persons with more severe to critical illness or severe immunocompromise likely remain infectious no longer than 20 days after symptom onset." That being said, data and clinical experience indicates a subset of patients that remain positive beyond the above prescribed period. In such instances, the clinician must use their clinical judgment to determine if the patient exhibits recurrent symptoms that are attributed to a recurrent COVID-19 infection and document the same in the patient’s medical record. If the patient is asymptomatic, the laboratory test will indicate persistent shedding of the virus; however, it does not equate to an acute infection given past the duration of 10-20 days as recommended by CDC and indicates a resolved COVID-19 infection. As a rule of thumb, indicators of a resolved COVID-19 infection used by our clinical documentation specialists and coding specialists are:

• Greater than 14 days since onset of symptoms or date of positive test
• Lack of COVID-19 treatment (Remdesivir, Decadron, etc.)
• No isolation

In the event of an acute COVID-19 active infection with Pulmonary manifestations, including pneumonia, acute respiratory failure, ARDS, etc., providers do not need to explicitly link the respiratory manifestation with COVID-19 since the causal relationship is implied, according to most recent coding guidelines.

However, with non-respiratory manifestations of an active COVID-19 infection, such as enteritis, thrombo-embolism resulting in cerebro-vascular accident, myocardial infarction, deep vein thrombosis, cytokine release syndrome, Guillain-Barre syndrome, etc., the causal relationship is not implied and the provider does need to explicitly link it with the following phrase, “…..due to a current COVID-19 infection.”

With respect to COVID-19 sequela, is a manifestation or complication that occurs after the COVID-19 acute infection has resolved. Coding guidance recommends the provider clearly document COVID-19 has resolved and link the sequela (e.g. heart failure, pneumonia, cytokine release syndrome, or thromboembolic complications to COVID-19).

At the end of the day, an accurate medical record is a service to our patients. Happy documentation!

Back to the April 2021 issue of Premier Pulse