Pulmonology Coding Alert

Question: A patient, who tested positive for COVID-19 a few days prior, presented to an urgent care clinic complaining of shortness of breath. The provider gathered the patient’s history and performed a physical examination. The patient claimed their symptoms had been mild thus far, but the shortness of breath was worrying them. The provider noted the shortness of breath was related to the COVID-19 infection. Then the provider prescribed the patient 20 mg of prednisone to be filled by a pharmacy and told the patient to return if the symptoms didn’t improve.

What codes do I need to report?

Arkansas Subscriber

Answer: You’ll assign two codes for this encounter — one for the COVID-19 infection and one for the shortness of breath. The patient has a confirmed diagnosis of COVID-19, so you’ll need to assign U07.1 (COVID-19) to reflect that the patient’s current

COVID-19 infection. The patient presented to the urgent care clinic complaining of shortness of breath, which the provider thought was related to the COVID-19 infection. You’ll assign R06.02 (Shortness of breath) after U07.1 on your report.

According to AHA Frequently Asked Questions Regarding ICD-10-CM Coding for COVID-19, “coding purposes, signs and symptoms associated with COVID-19 may be coded separately, unless the signs or symptoms are routinely associated with a manifestation (www.aha.org/fact-sheets/2022-04-13-frequently-asked-questions-regarding-icd-10-cm-coding-covid-19).

Reminder: Do not report U07.1 for patients who have residual symptoms but do not have an active COVID-19 infection. Use U09.9 (Post COVID-19 condition, unspecified) as the diagnosis for these patients, but only if the symptoms are related to having COVID-19 rather than the result of a different process. In these cases, you should report the symptom as the primary diagnosis, then the COVID-19 diagnosis — R06.02, U09.9.