These are the latest Guidelines for COVID.
g. Coronavirus infections
1) COVID-19 infection (infection due to SARS-CoV-2)
(a) Code only confirmed cases
Code only a confirmed diagnosis of the 2019 novel
coronavirus disease (COVID-19) as documented by
the provider or documentation of a positive COVID19 test result. For a confirmed diagnosis, assign code
U07.1, COVID-19. This is an exception to the hospital
inpatient guideline Section II, H. In this context,
“confirmation” does not require documentation of a
positive test result for COVID-19; the provider’s
documentation that the individual has COVID-19 is
sufficient.
If the provider documents "suspected," "possible,"
"probable," or “inconclusive” COVID-19, do not
assign code U07.1. Instead, code the signs and
symptoms reported. See guideline I.C.1.g.1.g.
(b) Sequencing of codes
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 a COVID-19 infection that progresses to sepsis, see
Section I.C.1.d. Sepsis, Severe Sepsis, and Septic Shock
See Section I.C.15.s. for COVID-19 infection in
pregnancy, childbirth, and the puerperium
See Section I.C.16.h. for COVID-19 infection in newborn
For a COVID-19 infection in a lung transplant patient,
see Section I.C.19.g.3.a. Transplant complications other
than kidney.
(c) Acute respiratory manifestations of COVID-19
When the reason for the encounter/admission is a
respiratory manifestation of COVID-19, assign code
U07.1, COVID-19, as the principal/first-listed
diagnosis and assign code(s) for the respiratory
manifestation(s) as additional diagnoses.
The following conditions are examples of
common respiratory manifestations of COVID-19.
(i) Pneumonia
For a patient with pneumonia confirmed as due to
COVID-19, assign codes U07.1, COVID-19, and
J12.89, Other viral pneumonia.
(ii) Acute bronchitis
For a patient with acute bronchitis confirmed as
due to COVID-19, assign codes U07.1, and J20.8,
Acute bronchitis due to other specified organisms.
Bronchitis not otherwise specified (NOS) due to
COVID-19 should be coded using code U07.1 and
J40, Bronchitis, not specified as acute or chronic.
(iii) Lower respiratory infection
If the COVID-19 is documented as being associated
with a lower respiratory infection, not otherwise
specified (NOS), or an acute respiratory infection,
NOS, codes U07.1 and J22, Unspecified acute lower
respiratory infection, should be assigned.
If the COVID-19 is documented as being associated
with a respiratory infection, NOS, codes U07.1 and
J98.8, Other specified respiratory disorders, should
be assigned.
(iv) Acute respiratory distress syndrome
For acute respiratory distress syndrome (ARDS)
due to COVID-19, assign codes U07.1, and J80,
Acute respiratory distress syndrome.
(v) Acute respiratory failure
For acute respiratory failure due to COVID-19,
assign code U07.1, and code J96.0-, Acute
respiratory failure.
(d) Non-respiratory manifestations of COVID-19
When the reason for the encounter/admission is a
non-respiratory manifestation (e.g., viral enteritis) of
COVID-19, assign code U07.1, COVID-19, as the
principal/first-listed diagnosis and assign code(s) for
the manifestation(s) as additional diagnoses.
(e) Exposure to COVID-19
For asymptomatic individuals with actual or suspected
exposure to COVID-19, assign code Z20.828, Contact
with and (suspected) exposure to other viral
communicable diseases.
For symptomatic individuals with actual or suspected
exposure to COVID-19 and the infection has been
ruled out, or test results are inconclusive or unknown,
assign code Z20.828, Contact with and (suspected)
exposure to other viral communicable diseases. See
guideline I.C.21.c.1, Contact/Exposure, for
additional guidance regarding the use of category
Z20 codes.
If COVID-19 is confirmed, see guideline I.C.1.g.1.a.
(f) Screening for COVID-19
During the COVID-19 pandemic, a screening code is
generally not appropriate. For encounters for
COVID-19 testing, including preoperative testing,
code as exposure to COVID-19 (guideline
I.C.1.g.1.e).
Coding guidance will be updated as new information
concerning any changes in the pandemic status
becomes available.
(g) Signs and symptoms without definitive diagnosis of
COVID-19
For patients presenting with any signs/symptoms
associated with COVID-19 (such as fever, etc.) but a
definitive diagnosis has not been established, assign the
appropriate code(s) for each of the presenting signs
and symptoms such as:
• R05 Cough
• R06.02 Shortness of breath
• R50.9 Fever, unspecified
If a patient with signs/symptoms associated with
COVID-19 also has an actual or suspected contact
with or exposure to COVID-19, assign Z20.828,
Contact with and (suspected) exposure to other viral
communicable diseases, as an additional code.
(h) Asymptomatic individuals who test positive for
COVID-19
For asymptomatic individuals who test positive for
COVID-19, see guideline I.C.1.g.1.a. Although the
individual is asymptomatic, the individual has tested
positive and is considered to have the COVID-19
infection.
(i) Personal history of COVID-19
For patients with a history of COVID-19, assign
code Z86.19, Personal history of other infectious and
parasitic diseases.
(j) Follow-up visits after COVID-19 infection has
resolved
For individuals who previously had COVID-19 and
are being seen for follow-up evaluation, and
COVID-19 test results are negative, assign codes
Z09, Encounter for follow-up examination after
completed treatment for conditions other than
malignant neoplasm, and Z86.19, Personal history of
other infectious and parasitic diseases.
(k) Encounter for antibody testing
For an encounter for antibody testing that is not
being performed to confirm a current COVID-19
infection, nor is a follow-up test after resolution of
COVID-19, assign Z01.84, Encounter for antibody
response examination.
Follow the applicable guidelines above if the
individual is being tested to confirm a current
COVID-19 infection.
For follow-up testing after a COVID-19 infection,
see guideline I.C.1.g.1.j.
4. Signs and symptoms
Codes that describe symptoms and signs, as opposed to diagnoses, are
acceptable for reporting purposes when a related definitive diagnosis has not
been established (confirmed) by the provider. Chapter 18 of ICD-10-CM,
Symptoms, Signs, and Abnormal Clinical and Laboratory Findings, Not
Elsewhere Classified (codes R00.0 - R99) contains many, but not all, codes for
symptoms.
See Section I.B.18 Use of Signs/Symptom/Unspecified Codes
5. Conditions that are an integral part of a disease process
Signs and symptoms that are associated routinely with a disease process should
not be assigned as additional codes, unless otherwise instructed by the
classification.
6. Conditions that are not an integral part of a disease process
Additional signs and symptoms that may not be associated routinely with a
disease process should be coded when present.
C. Uncertain Diagnosis
If the diagnosis documented at the time of discharge is qualified as “probable,”
“suspected,” “likely,” “questionable,” “possible,” or “still to be ruled out,”
“compatible with,” “consistent with,” or other similar terms indicating uncertainty,
code the condition as if it existed or was established. The bases for these guidelines
are the diagnostic workup, arrangements for further workup or observation, and initial
therapeutic approach that correspond most closely with the established diagnosis.
Note: This guideline is applicable only to inpatient admissions to short-term, acute,
long-term care and psychiatric hospitals
