ICD-10-CM Coding and Reporting Guidelines
October 1, 2020 through September 30, 2021
Chapter 1: Certain Infectious and Parasitic Diseases (A00-B99)
- 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 COVID-19 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
- (ii) Acute bronchitis
- (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.
- (iv) Acute respiratory distress syndrome
- (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 Z03.818, 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:
If a patient with signs/symptoms associated with COVID-19 also has an actual or suspected contact with or exposure to someone who has 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.
- (a) Code only confirmed cases
- 1) COVID-19 infection (infection due to SARS-CoV-2)
Chapter 16: Certain Conditions Originating in the Perinatal Period (P00-P96)
- s) COVID-19 infection in pregnancy, childbirth, and the puerperium
During pregnancy, childbirth or the puerperium, when COVID-19 is the reason for admission/encounter , code O98.5-, Other viral diseases complicating pregnancy, childbirth and the puerperium, should be sequenced as the principal/first-listed diagnosis, and code U07.1, COVID-19, and the appropriate codes for associated manifestation(s) should be assigned as additional diagnoses. Codes from Chapter 15 always take sequencing priority.
If the reason for admission/encounter is unrelated to COVID-19 but the patient tests positive for COVID-19 during the admission/encounter, the appropriate code for the reason for admission/encounter should be sequenced as the principal/first-listed diagnosis, and codes O98.5- and U07.1, as well as the appropriate codes for associated COVID-19 manifestations, should be assigned as additional diagnoses.
Chapter 16: Pregnancy, Childbirth, and the Puerperium (O00-O9A)
- h) COVID-19 Infection in Newborn
For a newborn that tests positive for COVID-19, assign code U07.1, COVID-19, and the appropriate codes for associated manifestation(s) in neonates/newborns in the absence of documentation indicating a specific type of transmission. For a newborn that tests positive for COVID-19 and the provider documents the condition was contracted in utero or during the birth process, assign codes P35.8, Other congenital viral diseases, and U07.1, COVID-19. When coding the birth episode in a newborn record, the appropriate code from category Z38, Liveborn infants according to place of birth and type of delivery, should be assigned as the principal diagnosis.
Chapter 21: Factors influencing health status and contact with health services (Z00-Z99)
- 6) Observation
There are three observation Z code categories. They are for use in very limited circumstances when a person is being observed for a suspected condition that is ruled out. The observation codes are not for use if an injury or illness or any signs or symptoms related to the suspected condition are present. In such cases the diagnosis/symptom code is used with the corresponding external cause code.
The observation codes are primarily to be used as a principal/first-listed diagnosis. An observation code may be assigned as a secondary diagnosis code when the patient is being observed for a condition that is ruled out and is unrelated to the principal/first-listed diagnosis (e.g., patient presents for treatment following injuries sustained in a motor vehicle accident and is also observed for suspected COVID-19 infection that is subsequently ruled out). Also, when the principal diagnosis is required to be a code from category Z38, Liveborn infants according to place of birth and type of delivery, then a code from category Z05, Encounter for observation and evaluation of newborn for suspected diseases and conditions ruled out, is sequenced after the Z38 code. Additional codes may be used in addition to the observation code, but only if they are unrelated to the suspected condition being observed.
NEW COVID-19 ICD-10 Code
- U07.1 2019-nCoVacute respiratory disease