Otolaryngology Coding Alert

Not sure which ICD-10 code to list first? Consider these strategies.

Sequencing COVID-19 among other concurrent and clinically relevant diagnoses can be tricky, even when you’ve got access to the guidelines. While the rules outlined in the ICD-10-CM guidelines may technically have all the answers you need, there’s more than a few instances where a misinterpretation can lead you to the wrong sequence of codes — or the wrong code altogether.

Unsurprisingly, “the major changes to the guidelines for FY 2021 involve the addition of rules with regard to COVID-19,” says RN and certified coder Melanie Witt, an independent coding expert based in Guadalupita, New Mexico. But as you’ll see in some of the following FAQs surrounding COVID-19 coding, the guidelines can often only take you so far.

Check out these three common coding scenarios so there’s no seconding-guessing the next time a dictation report featuring a COVID-19 diagnosis hits your desk.

How Can You Report COVID-19, Flu Concurrently?

Question 1: Our otolaryngologist treated a patient that was confirmed to have both influenza A and COVID-19. A prior computerized tomography (CT) scan revealed COVID-19 respiratory manifestations. Is there a combination code for these two diagnoses?

Answer 1: Unfortunately, ICD-10 doesn’t include one single code that will cover both of these conditions. If a patient is confirmed to have both influenza A and COVID-19 during the encounter, you will report each code separately, with the code for the novel coronavirus being listed first, as follows:

• U07.1 (COVID-19)
• J09.X2 (Influenza due to identified novel influenza A virus with other respiratory manifestations)

Which Code Applies to a Patient Post-COVID-19 Recovery?

Question 2: I’m coding a chart for a patient admitted to the hospital with COVID-19 that subsequently went home after recovering from the disease and testing negative. He presented to our office complaining of a chronic headache and congestion. The patient’s previous maxillofacial CT scan revealed no abnormalities. The patient was left with a diagnosis of a headache and nasal congestion. Do we use the COVID-19 code for this visit?

Answer 2: No, if the patient no longer has an active case of COVID-19, you should not report U07.1. Instead, you’ll report the codes for the diagnoses the otolaryngologist addressed, as well as the appropriate “Z” codes to represent the history of coronavirus. Therefore, your coding would appear as follows:

• R09.81 (Nasal congestion)
• R51.9 (Headache, unspecified)
• Z09 (Encounter for follow-up examination after completed treatment for conditions other than malignant neoplasm)
• Z86.19 (Personal history of other infectious and parasitic diseases)

The American Hospital Association’s (AHA’s) “Frequently Asked Questions Regarding ICD-10-CM Coding for COVID-19” advises practices to report these two Z codes “when a patient who previously had COVID-19 is seen for a follow-up exam and the COVID-19 test is negative.” These two codes should be sequenced after the conditions that the physician actually treated, which in this case puts them in the third and fourth positions.

How Should You Report COVID-19 Diagnosed After the Fact?

Question 3: Our otolaryngologist is treating a patient previously admitted to the hospital with a suspected case of COVID-19 for related vocal cord dysfunction. We found out after the patient had been discharged that he had indeed tested positive for the novel coronavirus. The patient’s chart was addended to include these results. Which diagnosis code do we report?

Answer 3: First, it’s important to consider AHA guidelines on how to report COVID-19 diagnoses when the positive test result comes back following discharge. “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,” the AHA says in its FAQs.

However, an even more important point to address is the common misconception that if a patient has a positive COVID-19 diagnosis, U07.1 should automatically be placed as the first-listed diagnosis. On the contrary, the ICD-10-CM guidelines make it clear as to how to sequence U07.1 in section I.C.1.g.1.b:

• “When COVID-19 meets the definition of principal diagnosis, code U07.1, COVID-19, should be sequenced first, 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.”

To consider: Keep in mind that the terms principal versus first-listed diagnoses are interchangeable when referenced in Section I of the ICD-10-CM guidelines.

This means that in the clinical example above, the primary diagnosis is J38.3 (Other diseases of vocal cords) since that was the reason the patient was seen in your office. Furthermore, since the chart has an updated result of the patient’s COVID-19 test, you can refer back to the AMA guidelines above and include U07.1 as a secondary diagnosis.