Coronavirus: Clinical Documentation Improvement and Coding Considerations

Coronavirus Electron microscopic image Source: CDC

by Richard Pinson, MD, FACP, CCS and Mary Beth York, CCS, CCS-P, CIC

2019 coronavirus disease (COVID-19) is the collective term for all respiratory infections caused by SARS-CoV-2. Initial symptoms are much like almost any significant respiratory infection such as fever and/or respiratory-like symptoms like cough, sneezing, shortness of breath and difficulty breathing. In more severe cases, infection can cause pneumonia, respiratory failure, acute kidney injury and even death especially among people over age 60 and/or those with significant chronic diseases. The disease appears to be less severe in children and people less than age 60.

When SARS-CoV-2 attacks it settles down in the body’s cells where it multiplies exponentially before causing symptomatic infection. This period between invasion and disease is called the “latent” (silent) period lasting 2-14 days during which the host is infectious to others.

The apparently healthy, unsuspecting host goes around as usual all the while shedding viruses that infect others. Just like the flu, transmission occurs via aerosol droplets from coughing and sneezing, and also by contact with contaminated surfaces. Hand-to-hand and hand-to-surface are the primary mechanisms of contact transmission, hence the important of frequent hand washing and sanitary gels.

Treatment is primarily supportive focusing on the complications. There are no known effective anti-viral drugs but some are being tested. Prevention is the best defense.

The ICD-10 code for SARS-CoV-2 is U07.1 (COVID-19). U07.1 is assigned first followed by a code for the associated respiratory infection/condition:

  • Pneumonia – assign U07.1 (COVID-19) -> J12.89 (other viral pneumonia).
  • Acute bronchitis – assign U07.1 (COVID-19) -> J20.8 (acute bronchitis due to other specified organisms).
  • Bronchitis (unspecified acuity) – assign U07.1 (COVID-19) -> J40 (unspecified bronchitis).
  • Other lower respiratory infections – assign U07.1 (COVID-19) -> J22 (unspecified acute lower respiratory infection).
  • Respiratory infection – assign U07.1 (COVID-19) -> J98.8 (other specified respiratory infection).
  • ARDS – assign U07.1 (COVID-19) -> J80 (ARDS)

Only confirmed cases of COVID-19 are coded U07.1. A confirmed diagnosis is defined as the documented diagnostic statement of COVID-19 by the provider, or documentation of a positive COVID-19 test result or “presumptive” positive COVID-19 test result. Per the Official Guidelines for Coding and Reporting, we never assign a diagnosis code based on an abnormal laboratory unless the provider indicates the clinical significance. A positive COVID-19 test result is coded as U07.1. This is an exception to the Abnormal findings guideline and is applicable to COVID-19 test result only. This guideline application is confirmed by the April 1, 2020 AHA webinar.

A “presumptive” positive test is one that has been reported positive by a local or state laboratory but not confirmed by CDC.

Do not assign code U07.1 for provider documentation of likely, suspected, presumptive COVID (different from “presumptive” positive test), or using other terms of uncertainty, as a diagnosis. Instead assign a code(s) explaining the reason for encounter (such as fever) or Z20.828, Contact with and (suspected) exposure to other viral communicable diseases. A query for clarification is warranted when a provider documents likely, suspected, presumptive COVID, but the lab test result is reported as positive.

Where concern for possible COVID-19 exposure is documented, but ruled out after evaluation, assign code Z03.818 (encounter for observation for suspected exposure to other biological agents ruled out). For cases where an actual exposure to someone who is confirmed or suspected to have COVID, and the exposed person either tests negative or test results are unknown, assign code Z20.828 (contact with and [suspected] exposure to other viral communicable diseases).

For asymptomatic individuals with no known exposure to the virus who are being screened for COVID-19 and the test result is negative or unknown, assign code Z11.59 (encounter for screening for other viral diseases). For asymptomatic persons who test positive for the virus, assign U07.1 (COVID-19).

For COVID-19 infections presenting during pregnancy, childbirth and the puerperium, assign a code from O98.5- (other viral diseases complicating pregnancy, childbirth and the puerperium) following by U07.1 and the pertinent code for the associated infection.


  • Coronavirus disease 2019 (COVID-19)
  • CDC: ICD-10-CM Official Coding Guidelines April 1, 2020 through September 30, 2020 Section I.C.1.g.(1), COVID-19 Infections (Infections due to SARS-CoV-2).


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About the Authors

Dr. Richard Pinson, MD, FACP, CCS
Dr. Richard Pinson is a physician, educator, administrator, and healthcare consultant. He practiced Internal Medicine and Emergency Medicine in Tennessee for over 20 years having board certification in both. Dr. Pinson is a Fellow of the American College of Physicians and former Assistant Professor of Clinical Medicine at Vanderbilt, and has assisted hospitals as a physician consultant for the past ten years. Dr. Pinson’s personal understanding of the mindset of both doctors and managers allows him a unique vantage point from which to promote cooperation between physicians, hospital staff, and administrators toward achieving beneficial and practical changes.

Mary Beth York, CCS, CCS-P, CIC
Mary Beth York has over twenty year’s experience in coding, auditing and documentation improvement for hospitals ranging from community to teaching hospitals as well as physician group practices. Mary Beth is the author of Libman Education’s highly successful CCS Exam Prep course, as well as Libman Education’s highly successful CCA Exam Review course.

About the Author

Libman Education
Libman Education Inc. is a leading provider of training for the health care workforce offering self-paced and instructor-led online courses designed and developed by leading industry experts in Health Information Management (HIM) and Medical Record Coding. Our courses are specifically designed to improve individual skills and increase the efficiencies and competencies of health care providers and institutions. At Libman Education, we understand the needs and challenges of a well-trained workforce and offer the right-mix of online education to ensure that the health care professionals are prepared to meet the challenges of the changing workplace.

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