Female ent doctor and patient in office, exam

There is some confusion on the “for” or “with” COVID-19 diagnosis.

From the start of the pandemic, some people have downplayed COVID-19 deaths, particularly those in patients with medical co-morbidities. And now that we are seeing more reports of incidental COVID, it begs the question: what does it mean to be diagnosed “for” COVID-19, U07.1 (principal diagnosis), as opposed to “with” incidental COVID-19, or secondary diagnosis, U07.1, when another specified diagnosis is the reason for admission?

For one thing, this issue has emerged because the pandemic has changed, and continues to change, with different COVID variants. Until recently, the vast majority of hospitalized patients testing positive for COVID-19 were there because of COVID complications, mostly involving the lungs. Plenty of hospitalized COVID patients still fit that description, as we have heard published reports from New York, New Jersey, and California hospitals this past week.

However, now we are learning that there is a distinction between admitted “with” (incidental) and “for” (principal) COVID-19, and it is surprisingly nuanced, based on the methods used by the coder and/or provider to reach their diagnostic conclusions.

As a professional coder and auditor, I am constantly reviewing physicians’ charting and reporting, and I have noticed that while coders have to be objective in their coding application, the physicians often use subjective judgment when adding their documentation insights, which can make achieving accurate coding a challenge.  

For example, on the question of “with COVID,” the complexity of the issue is easily seen when looking at specific patients. One male in his 70s with a history of cardiovascular disease clearly had been suffering from COVID at home. His primary symptom at first was a cough and some shortness of breath, but then he passed out and was brought to the hospital by ambulance. He was admitted with a diagnosis of cardiac arrest (acute MI), and upon admission to the hospital, soon showed evidence of severe COVID pneumonia. Now, while clinical notes all cited his COVID infection, a cursory search of the diagnostic codes in the medical record might have led to a characterization of the patient as having “incidental” COVID, or being “with COVID-19,” because cardiac arrest, not COVID, was the reason for his admission. Is this accurate? In my professional opinion, no. But I would first query the admitting provider to make that call.

Now, let’s look at a truly incidental COVID-19 case. For example, our local hospital has cared for several younger vaccinated patients who were admitted for non-COVID-related problems like appendicitis; they tested positive, upon routine screening, but were asymptomatic. Among older adults, a man in his 60s with stage IV prostate cancer was admitted for kidney failure, and then tested positive for the coronavirus — another straightforward case of incidental covid.

But even there, while characterizing his case as incidental would be clinically accurate, it might inadvertently minimize the impact of that patient – and others like him – on the healthcare system. First, we don’t know how his COVID will progress. Also, a missed consideration here is that every COVID patient, incidental or not, needs to be treated as infectious, which translates into time-consuming isolation procedures for hospital personnel.

In some cases, the question of whether a hospitalization is “for” COVID seems unanswerable. We have seen patients with sickle-cell disease or severe fibromyalgia, admitted because they were in intense pain – yet they also tested positive for COVID-19. While severe body aches are a trademark of sickle-cell crisis, COVID can also cause severe body pain. So, while we might be inclined to put these patients in the incidental COVID category, a relatively mild case of COVID may have triggered their sickle pain crisis. Similarly, another patient admitted with a lower extremity blood clot who tested positive for COVID and displayed symptoms relating to COVID was not technically hospitalized “for” COVID. So, should this be coded as incidental COVID, even though our early history of this virus has confirmed that COVID increases the risk of blood clots?

Another new challenge with this highly contagious variant, Omicron, are patients who acquire the virus during their hospitalization. A coding and reporting consideration that hinges on admission diagnoses for COVID-related illness would characterize such patients as having incidental COVID, even though COVID will undoubtedly increase the length of their stay (and, for some, their risk of a bad outcome).

Given this complexity, what we are all looking for is a consistent and standardized method to determine the fraction of hospitalized COVID patients who might correctly be characterized as having incidental COVID. Every state’s and every hospital’s methodology, and every provider’s judgment, is different.

The split between “with” or “because of” (for) COVID-19 isn’t entirely clear-cut, New Jersey Health Commissioner Judith Persichilli said during a recent briefing.

As reported in the Jan. 17 edition of Becker’s Hospital News, officials from New York City-based NYU Langone Health told The New York Times in a Jan. 4 report that about 65 percent of its COVID-19 patients were “incidentally” found to be infected after admission for other reasons.

New York Gov. Kathy Hochul asked hospitals to adjust their reporting on COVID-19 hospitalizations, beginning Jan. 4, to make the distinction between those admitted for the virus as their primary condition and those who incidentally test positive, or with COVID-19.

In a series of comments on Twitter on Jan. 4, Ashish Jha, MD, dean of Brown University’s School of Public Health in Providence, R.I., who practices at Providence VA Medical Center, explained the distinction between patients hospitalized “for COVID-19” and those hospitalized “with COVID-19.”   

“We have a few patients in the hospital for COVID, but not many, thank goodness,” Dr. Jha tweeted. “More common on our service is folks admitted with COVID. That is, they came to the hospital for something else and found to have COVID.” Although it’s tempting to dismiss such cases as incidental, they can still pose significant risks for patients with other issues, complicate care, and add stress to the health system, Dr. Jha said. 

So, as you can see, there is still some confusion on the “for” or “with” COVID-19 diagnosis, but for accuracy, and in the trusted words of Dr. Erica Remer, ICD10monitor.com Co-Host and author of the ICD10 Coding Flow Charts, “clinical documentation integrity (CDI) is more important than ever, in the age of COVID-19. It is critical that we ensure that providers are documenting accurately, and that coders are picking up the right codes in the correct sequence.”

Programming Note: Listen to Terry Fletcher report this story live today during Talk Ten Tuesdays, 10 Eastern.

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