The COVID-19 pandemic necessitated rapid updates to medical coding practices, and the introduction of the ICD-10 code U07.1 for COVID-19 was a significant change. Initially announced by the World Health Organization (WHO) as a pandemic in March 2020, and declared a national emergency in the US shortly after, COVID-19 required immediate and accurate reporting in medical claims and surveillance data. This urgency led the Centers for Disease Control (CDC) to accelerate the implementation of ICD-10 diagnosis code U07.1, COVID-19, making it effective from April 1, 2020, instead of the usual October cycle. This article delves into the guidelines around using U07.1 as a primary diagnosis, offering clarity for healthcare professionals and medical coders.
Decoding ICD-10-CM Code U07.1 and Primary Diagnosis
The CDC, through the National Center for Health Statistics (NCHS), provided essential updates to the ICD-10-CM coding system to incorporate COVID-19. These updates included addenda to the ICD-10-CM Index and crucial tabular notes that accompany the U07.1 code. Crucially, these notes specify the use of additional codes to identify associated conditions like pneumonia, providing essential sequencing instructions for coders. Understanding these instructions is key to determining when U07.1 can serve as a primary diagnosis.
Official Guidelines: When is U07.1 the Principal Diagnosis?
The CDC/NCHS released Official Coding and Reporting Guidelines, effective from April 1, 2020, through September 30, 2020, to accompany the introduction of U07.1. These guidelines, found within Chapter 1 (Infectious Diseases) and Chapter 15 (Pregnancy, Childbirth, and the Puerperium) of the ICD-10-CM, explicitly address when COVID-19 should be sequenced as the principal diagnosis.
COVID-19 Infections: Confirmed Cases and Coding
According to the guidelines, code U07.1 should only be assigned for confirmed cases of COVID-19. Confirmation is defined as documentation by the provider of a COVID-19 diagnosis, a positive COVID-19 test result, or a presumptive positive test result. Notably, the guidelines clarify that “confirmation” doesn’t necessitate the type of test documented; the provider’s statement that the patient has COVID-19 is sufficient. Presumptive positive results, indicating a positive local or state test awaiting CDC confirmation, are also to be coded as confirmed COVID-19.
However, it’s equally important to note when not to use U07.1. If the provider documents terms like “suspected,” “possible,” “probable,” or “inconclusive” COVID-19, code U07.1 should not be assigned. In these scenarios, coders should use codes that explain the reason for the encounter, such as symptoms like fever (R50.9) or exposure to viral communicable diseases (Z20.828).
Sequencing U07.1 as Principal Diagnosis
The guidelines explicitly state that when COVID-19 meets the definition of principal diagnosis, U07.1, COVID-19, should be sequenced first. This is followed by codes for any associated manifestations, such as pneumonia or acute bronchitis. The exception to this sequencing rule is in obstetrics cases, detailed further in Section I.C.15.s of the guidelines for COVID-19 in pregnancy, childbirth, and the puerperium where Chapter 15 codes take priority.
For instance, if a patient is admitted primarily for COVID-19 pneumonia, the coding sequence would be U07.1 (COVID-19) first, followed by J12.89 (Other viral pneumonia). This sequencing clearly establishes COVID-19 as the primary reason for admission and care.
COVID-19 Coding Guidelines
Manifestations and Co-existing Conditions with COVID-19
The guidelines further clarify coding for specific acute respiratory illnesses related to COVID-19:
- Pneumonia due to COVID-19: Assign U07.1 and J12.89 (Other viral pneumonia).
- Acute Bronchitis due to COVID-19: Assign U07.1 and J20.8 (Acute bronchitis due to other specified organisms). For bronchitis NOS due to COVID-19, use U07.1 and J40 (Bronchitis, not specified as acute or chronic).
- Lower Respiratory Infection due to COVID-19: For unspecified lower respiratory infection (NOS) or acute respiratory infection (NOS) associated with COVID-19, assign U07.1 and J22 (Unspecified acute lower respiratory infection). For respiratory infection NOS, use U07.1 and J98.8 (Other specified respiratory disorders).
- Acute Respiratory Distress Syndrome (ARDS) due to COVID-19: Assign U07.1 and J80 (Acute respiratory distress syndrome).
In each of these cases, U07.1 is sequenced first when COVID-19 is the principal diagnosis, highlighting its role in initiating the condition.
Special Scenarios: Exposure, Screening, and Asymptomatic Cases
The guidelines also address scenarios beyond symptomatic confirmed cases, further clarifying the scope of U07.1 and primary diagnosis considerations:
- Exposure to COVID-19 Ruled Out: If exposure is suspected but ruled out after evaluation, assign Z03.818 (Encounter for observation for suspected exposure to other biological agents ruled out). U07.1 is not used here as COVID-19 is not confirmed.
- Actual Exposure with Negative or Unknown Test: For actual exposure to confirmed or suspected COVID-19 cases where the exposed individual tests negative or results are unknown, assign Z20.828 (Contact with and (suspected) exposure to other viral communicable diseases). Again, U07.1 is not applicable without confirmation.
- Screening for COVID-19 in Asymptomatic Individuals: For asymptomatic individuals screened for COVID-19 without known exposure and with negative or unknown results, use Z11.59 (Encounter for screening for other viral diseases). U07.1 is not used unless the screening is positive.
- Asymptomatic Individuals Testing Positive: Even in the absence of symptoms, if an individual tests positive for COVID-19, assign U07.1. In this case, while asymptomatic, the positive test confirms infection, making U07.1 the appropriate diagnosis code, and potentially the primary diagnosis depending on the encounter’s purpose.
COVID-19 in Pregnancy, Childbirth, and the Puerperium
For pregnant patients admitted due to COVID-19, or encountering healthcare for COVID-19 related issues during pregnancy, childbirth, or puerperium, the principal diagnosis code is O98.5- (Other viral diseases complicating pregnancy, childbirth, and the puerperium), followed by U07.1 and codes for manifestations. In these obstetric cases, Chapter 15 codes take sequencing precedence, meaning U07.1 is not the principal diagnosis in terms of sequencing, but it is still a crucial secondary code to specify the COVID-19 infection.
Conclusion: U07.1 as Primary Diagnosis – Clarity and Application
In conclusion, U07.1, COVID-19, can indeed be a primary diagnosis when COVID-19 is the main reason for a healthcare encounter and is confirmed through provider documentation or positive test results. The CDC guidelines clearly direct coders to sequence U07.1 first in most scenarios, followed by manifestation codes, solidifying its role as a principal diagnosis code in these cases. Understanding these guidelines is paramount for accurate coding, billing, and public health data tracking during and beyond the pandemic. For ongoing updates and further learning, resources like the CDC/NCHS website and specialized COVID-19 coding training programs are invaluable for healthcare professionals.
