COVID-19 Documentation Requirements
Published on April 23, 2020
With the CARES Act Provider Relief Fund comes a new reporting requirement. Providers need to make sure they are documenting all COVID-19 patients that they are treating. There are a few ways that anesthesia providers can help to ensure that all these cases are captured accurately.
COVID-19 Positive Cases
These are cases which have a confirmed lab result for COVID-19. They should be documented with COVID-19. Providers should also be careful to document any additional manifestations of the disease, such as ARDS or pneumonia, as well as the primary diagnosis which necessitates the anesthesia care, the reason for surgery.
Suspected COVID-19 Cases
These are patients in which COVID-19 is suspected based on symptoms and exposure, but there is not a confirmed lab result yet. These cases should not be documented as COVID-19 positive. If the results are not back, it is vital to document that COVID-19 is suspected. Additionally, providers should list any associated symptoms as well as the primary diagnosis for anesthesia care.
Finally, in the absence of a definitive diagnosis, highly trained medical coders can search patient records to ensure that the diagnostic information reported is accurate. In patients who have indications of respiratory conditions, the coder can review documentation to confirm whether the patient has a COVID-19 diagnosis, and where confirmed, code it as an underlying or primary diagnosis.
The following is a list of codes which would be potentially indicated. It is important that these cases are coded accurately with the COVID-19 diagnosis when it applies.
Prior to April 1st DOS B97.29 - Other coronavirus as the cause of diseases classified elsewhere.
Effective April 1st DOS U07.1 - COVID-19 (Use additional code(s) to identify pneumonia or other manifestations.)
Diagnoses which may indicate an underlying dx of COVID-19:
J80 – ARDS (Acute Respiratory Distress Syndrome)
R06.3 – Respiratory Distress
J96.00 – J96.92 – Respiratory Failure
J12.9, J18.9 – Pneumonia
Z99.1 – Vent Dependence
Procedures which may indicate an underlying dx of COVID-19:
31500 – Intubation
36620 – A-line
36556 – C-line
94002 – 94003 - Vent Management
31600 – Tracheostomy
31622 – 31654 – Bronchoscopy
The above is not an all-inclusive list, but rather a suggested starting point for queries.
In this difficult time, it is more important than ever for providers and their billing partners to work together in the fight against COVID-19. At PPM Partners, we’re here and ready to take on the challenge.
By Heather E. Golfos, CPC, CANPC
Coding Department Manager