No Codes for COVID Manifestations

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Original story posted on: June 15, 2020

Some doctors don’t understand how coders compliantly select codes. This can set up coding-clinical disconnects. Frankly, I don’t always get it myself, and I’m pretty good at this coding thing.

You need to use exact verbiage…except when you don’t. Like no doctor is ever going to say, “hemorrhagic disorder due to extrinsic circulating anticoagulants.” The wording of many of the social determinants of health (SDoH) will not be matched precisely by the provider’s documentation.

Sometimes, Coding Clinic gives guidance on what verbiage is allowed to go to what code, and sometimes coders just use common sense. The indexing of the verbiage of “Kawasaki disease” goes nowhere, but “Kawasaki” is a nonessential modifier for the code titled Mucocutaneous lymph node syndrome, M30.3, and “Kawasaki’s syndrome” does index there. However, a clinical documentation improvement specialist (CDIS) or coder would meet with annoyance and resistance if they asked the provider to clarify, did they mean “Kawasaki’s syndrome” when they documented “Kawasaki disease?”



Why am I bringing this up today? There are multiple manifestations of COVID-19 that make for clever acronyms, but won’t yield an ICD-10-CM code. The pediatric Multisystem Inflammatory Syndrome of Children (MIS-C) is quite serious, and is manifested by different body parts becoming inflamed, including the heart, lungs, kidneys, brain, skin, eyes, and/or gastrointestinal organs. It is described as having Kawasaki disease-like features. There is no indexing for MIS-C. “Kawasaki disease-like features” isn’t going to get you anywhere either.

You would need the provider to specify which organs are inflamed, again, using codable terminology. Is it an unspecified arteritis (because it isn’t a chronic ischemic issue)? Is it a sequela of COVID-19, or an acute manifestation? An infective myocarditis or infective pericarditis implies that the heart is infected by the virus currently, whereas I40.8, Other acute myocarditis, might be more appropriate with B94.8, Sequelae of other specified infectious and parasitic diseases.

In the same vein, Multiple Organ Dysfunction Syndrome (MODS) indexes nowhere. Speaking as a clinician, if I had a patient with MODS from an infection, I would call that sepsis. I recommend that you educate your providers to diagnose “sepsis from COVID-19 with acute sepsis-related organ dysfunction, as evidenced by (and here they should list the specific organ dysfunctions).”

How about “COVID toes,” described as red or purple discoloration of the toes with paresthesia? Dermatologists liken it to chilblains or pernio, which is a reaction to cold exposure. They may also describe it as a vasculitis. It may be optimal for the provider to expound upon “COVID toes,” because there is no specific code for it, and the medical community is trying to maintain a registry. Perhaps “COVID toes (i.e., pernio)” would work.

Be on the lookout for new acronyms and abbreviations that may crop up as COVID-19 medicine evolves. If the provider documents a diagnosis for which there is no indexing or advice to assign a code, you may need to educate and query. We can’t monitor what we can’t measure, and we need accurate codes to measure the manifestations of COVID-19.

Listeners, if you are participating in protests, or only just going about your daily COVID-19 lives, please remember to maintain social distance, and wear your mask correctly.

Programming Note: Listen to Dr. Erica Remer every Tuesday on Talk Ten Tuesdays, 10-10:30 a.m. EST.

Erica E. Remer, MD, FACEP, CCDS

Erica Remer, MD, FACEP, CCDS has a unique perspective as a practicing emergency physician for 25 years, with extensive coding, CDI, and ICD-10 expertise. She was a physician advisor of a large multi-hospital system for four years before transitioning to independent consulting in July 2016. Her passion is educating CDI specialists, coders, and healthcare providers with engaging, case-based presentations on documentation, CDI, and denials management topics. She has written numerous articles and serves as the co-host of Talk Ten Tuesdays, a weekly national podcast. Dr. Remer is a member of the ICD10monitor editorial board, the ACDIS Advisory Board, and the board of directors of the American College of Physician Advisors.

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