Radiology 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 FAQ’s 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 radiologist interpreted a computerized tomography (CT) scan of an inpatient who was confirmed to have both influenza A and COVID-19. The scan revealed COVID-19 respiratory manifestations in the impression. 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 scan 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 independent diagnostic testing facility (IDTF) for imaging after complaining of a feeling of being constantly tired. There were no findings on the scan and the patient was left with a diagnosis of low iron levels and generalized weakness. 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 radiologist addressed, as well as the appropriate “Z” codes to represent the history of coronavirus. Therefore, your coding would appear as follows:

• E61.1 (Iron deficiency)
• R53.1 (Weakness)
• 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: I’m coding a chest CT scan for an inpatient who had a suspected case of COVID-19, but the scan revealed a partially collapsed lung without any other pulmonary findings. We found out after the patient had been discharged that he had indeed tested positive for the novel coronavirus. Furthermore, an addendum was included in the dictation report to include these results. Which diagnosis code do we report?

Answer 3: First, it’s important to consider AMA 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.”

For context, you can refer to a recent article in Radiology Coding Alert (v22n7) titled “Decode COVID-19 ICD-10-CM Guidelines With This Radiology Example.” Here, the subject of principal versus first-listed diagnoses is broached, ultimately concluding that the terms are interchangeable when referenced in Section I of the ICD-10-CM guidelines.

This means that in the clinical example above, you need further information to determine sequencing of codes. If the report indicates that the pulmonary collapse is the result of the COVID-19 diagnosis, then report U07.1 as the first-listed diagnosis. However, without that indication, coupled with the fact that there are no other pulmonary findings, you should not assume the lung collapse is related to the COVID-19 diagnosis. If you code the report as is, you will report a primary diagnosis of J98.11 (Atelectasis). Since the dictation report 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.