By Dr. Richard Pinson, MD, FACP, CCS
As the COVID-19 pandemic has progressed and evolved, it has been recognized that patients may experience a wide range of symptoms and complications after recovery from acute illness. Some aspects of this recovery may be unique to COVID-19, but many appear to be similar to recovery from other viral illnesses, critical illness and/or sepsis. Recognition, proper documentation, and correct coding of these symptoms and complications are essential since this is a huge public health issue. If the coded data is not complete, accurate medical knowledge and public health will suffer.
Three clinical categories of post-recovery symptoms and complications have been proposed:
- Acute: continuing up to 4 weeks following the onset of illness
- Ongoing symptomatic: continuing from 4 to 12 weeks following the onset of illness
- Post-COVID-19: symptoms and conditions that develop during or after COVID-19, continue for ≥ 12 weeks and are not explained by an alternative diagnosis
Acute and persistent symptoms may include respiratory symptoms: dyspnea, chest pain, cough, fatigue, loss of smell/taste, hair loss, joint pain, headache, dizziness, myalgias, and insomnia. Other potential respiratory problems including chronic cough, fibrotic lung disease, bronchiectasis, and pulmonary vascular disease with pulmonary hypertension.
COVID-19-induced hypercoagulable state may occur acutely or as a post-acute condition manifested as deep venous thrombosis, pulmonary embolism and arterial thromboembolism causing myocardial infarction, stroke, or limb ischemia. Cardiac sequelae include myocarditis, ischemic injury with elevation of troponin; myocardial infarction, cardiac vasculitis and endotheliitis, right heart strain (acute cor pulmonale) and stress (Takotsubo) cardiomyopathy.
Mental disorders like anxiety, depression, post-traumatic stress disorder [PTSD], impaired memory and cognitive impairment may occur. A few cases of post-COVID psychosis have been reported but further study is needed to determine if a causal relationship exists.
Microvascular disease of the brain, which can be seen on MRI, was reported in the New England Journal of Medicine on Dec. 20, 2020 as an acute complication. According to the authors, because limited clinical information was available, no conclusions can be drawn in relation to neurologic features of COVID-19. It would, however, be expected to have a long-term impact on brain function.
Cytokine release syndrome (CRS) or “cytokine storm” is now recognized as a not-uncommon complication of COVID-19 with onset ranging from early in the course of the disease to several weeks after COVID-19 symptoms have resolved. CRS is an acute systemic inflammatory syndrome characterized by fever and multiple organ dysfunction. It is often fatal. Five severity grades are recognized.
Multisystem inflammatory syndrome in children (MIS-C) is a rare but serious condition associated acutely with COVID-19. Symptoms may be similar to those of Kawasaki disease, Kawasaki disease shock syndrome, and toxic shock syndrome including persistent fever, hypotension, metabolic encephalopathy, seizures, hepatitis, gastrointestinal symptoms, rash, lymphadenopathy, myocarditis, pericarditis, myositis and laboratory findings associated with severe systemic inflammation (SIRS); respiratory symptoms may be absent. The nature and frequency of long-term complications from MIS-C are uncertain, given that it is a relatively new clinical entity and long-term follow-up studies are lacking.
Sixteen cases of purported adult MIS (MIS-A) with manifestations similar to MIS-C have been reported for the U.K. and USA.
Coding considerations are also important. Only confirmed cases of COVID-19 are coded U07.1. A confirmed diagnosis is defined as (1) a positive COVID-19 test result, or (2) provider documentation that the individual has COVID-19. Code U07.1 is assigned first followed by the appropriate codes for the associated manifestations unless otherwise specified by the classification (e.g., sepsis).
Code Z86.16, Personal history of COVID-19, is assigned for a patient who previously had COVID-19 but no longer has COVID or sequelae.
For patients admitted for a complication or sequela of a COVID-19 infection and the patient no longer has COVID-19, assign the code for the manifestation or complication followed by code B94.8, Sequelae of other specified infectious and parasitic diseases.
As an example, consider a patient hospitalized a few weeks ago for pneumonia due to COVID-19 who is readmitted with pneumothorax. The discharge diagnosis is “pneumothorax due to history of COVID-19.” Assign code J93.83, Other pneumothorax, as principal diagnosis followed by B94.8, Sequelae of other specified infectious and parasitic diseases. In this case, the patient no longer has COVID-19 (based on provider documentation) and the pneumothorax is a residual effect.
If the documentation is unclear regarding whether the provider considers a condition to be an acute manifestation of a current or unresolved COVID-19 infection vs. a residual effect from a previous or resolved COVID-19 infection, query the provider.
For 2021, a new code (M35.81) was created for MIS-C and MIS-A. For coding purposes M35.81 is considered a CC. SIRS ought not be separately coded when M35.81 is assigned, since it is an intrinsic part of MIS-C.
Code sequencing for CRS as a late manifestation of COVID-19 following resolution is problematic because of conflicting “code first instructions.” The underlying cause of CRS is supposed to be sequenced first. However, if a patient is admitted with CRS due to a previous COVID-19 infection, the cause would be a resolved condition in which case, coding guidelines require assignment of the code for the manifestation followed by the sequela code (B94.8). In the absence of official guidance, the best option at this time would be assigning the CRS as the principal diagnosis followed by code B94.8. CRS grades 3 to 5 are CCs (codes D89.833-D89.835) when not the principal diagnosis.
In summary, COVID-19 patients may experience a wide range of symptoms and complications after recovery from acute illness. Clinically, these are classified according to time to onset but ICD-10-CM codes do not account for them. Code U07.1 (COVID-19) is assigned first followed by the appropriate codes for the associated manifestations unless otherwise specified by the classification. A new code, Z86.16 (Personal history of COVID-19), created for 2021, is assigned for a patient who previously had COVID-19 but no longer has COVID-19 or sequelae.
The Pinson & Tang CDI Pocket Guide provides specific standardized query templates for the most common medical conditions as well as instruction on how to modify the template to fit the particular circumstances of the case in question.
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About the Author
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.