The underlying etiology is sequenced first and the manifestation, or the presentation of the disease process, is coded second.

Recently I was listening to a podcast called Coder vs. CDI by my friend, Allen Frady, and his co-host, Amy Czahor, about how to code mild COVID-19 with other conditions; at one point, Allen mentioned he wanted to hear opinions from doctors. So here’s my opinion, as a doctor who plays a coder on the computer.

I know there is a coding hierarchy. I respect that there are rules and guidelines and conventions. But the bottom line of coding is that you are trying to tell the story of the clinical encounter. If you arrive at a set of codes that doesn’t reflect what happened in the visit, you need to revisit the codes assigned.

The Guidelines for the code for COVID-19 (, U07.1, state:

“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.”

When this first came out in April 2020, the only explicit exception was for obstetrics. The sepsis and transplant complication exceptions had to be added subsequently, because people read the original instruction as “code U07.1 first, all the time,” and this was leading to incorrect sequencing.

Home in on “meets the definition of principal diagnosis.” This pertains to patients with active COVID-19 infection. It is easy to recognize U07.1 when the patient has been home coughing for eight days and presents in acute hypoxic respiratory failure from a COVID-19-related pneumonia. The converse is also readily identifiable when the patient presents to the hospital for a completely unrelated condition and has an incidental positive (let’s presume a true positive), e.g., acute appendicitis with no respiratory manifestations.

The question Allen and Amy posed was how to sequence the ICD-10-CM codes if a patient has COVID-19, which at first blush wasn’t the reason for seeking medical attention, but also is not completely unrelated. The crux, in my opinion, is the age-old manifestation-etiology dilemma.

Doctors don’t really think about “manifestations” the same way coding rules lay it out. “Manifestation” literally means a display or expression. To me, a fever and a cough are a manifestation of pneumonia. But that’s not really how coding uses it. Coding uses it to indicate codable conditions that are related by cause and effect; they are “associated.” The Guidelines even state that “in most cases, the manifestation codes will have in the code title, ‘in diseases classified elsewhere,’” and they offer the example of “dementia in diseases classified elsewhere” being connected to Alzheimer’s disease. The underlying etiology is sequenced first and the manifestation, or the presentation of the disease process, is coded second.

The Guidelines specifically call out respiratory manifestations of COVID-19 (I.C.1.g.1)(c)), and they include examples of pneumonia, acute bronchitis, acute respiratory distress syndrome, or respiratory failure. I think acute respiratory failure is analogous to acute exacerbation of COPD, assuming the provider thinks the COVID-19 caused the exacerbation. Both are one step removed from being directly caused by the coronavirus. The viral infection/inflammation of the lung was caused primarily by COVID-19, and the acute respiratory failure or exacerbation of COPD occurred secondarily from the pulmonary involvement. U07.1 started the cascade, and is entitled to top billing as principal diagnosis. Often, those patients support coding of J44.0, COPD with (acute) lower respiratory infection, in addition to the J44.1, COPD with (acute) exacerbation.

However, let’s imagine that a patient with COPD or asthma gets infected with SARS-CoV-2, but they are asymptomatic or have non-respiratory symptoms like fatigue or diarrhea. Then they go into a friend’s newly painted home, which sets off their chronic respiratory illness, just like it always does. If they go to the hospital (and let’s say their chest X-ray is not suggestive of COVID-19 pneumonia), U07.1 could conceivably not be the trigger for their acute exacerbation, and shouldn’t be the PDx. As Allen mentions in his podcast, this is all dependent on how the provider documents the situation, but J44.1 might be the reason that occasioned the admission to the hospital – and U07.1 could be a secondary diagnosis in this hypothetical case.

Another scenario the podcast posed was heart failure (HF) exacerbation, perhaps from myocarditis as a residual effect of previous COVID-19. As Allen alluded to, this is comparable to the situation of multisystem inflammatory syndrome (MIS) when the COVID-19 is not believed to be current. The myocarditis or the MIS is the sequelae of the previous COVID-19 infection and should be coded as such (B94.8 until October 1, then U09.9). U07.1 isn’t on the menu. I’m going to leave the sequencing of myocarditis versus exacerbation of HF to the real coders.

Allen also pointed out that we are going to be seeing more false positives soon. We at Talk Ten Tuesdays and ICD10monitor did a whole series on false positives in COVID-19 some months ago with Dr. Andrew Cohen. The gist of it is that when the disease is very prevalent, positives are likely to indicate true disease, and when the disease is rare, false positives become much more likely. Clinical validation may be necessary for positive PCR results to determine whether the provider believes it signifies a true or false positive (i.e., is U07.1 a valid code at all?)

If you have to query, make sure you know what question you are asking. Here are some choices:

  • Do you think COVID-19 is causing condition X, or is coexistent but not related?
  • Do you think the (condition), as a manifestation from COVID-19, is the reason the patient was admitted to the hospital?
  • Is this an acute COVID-19 infection, ongoing symptomatic COVID-19 (FYI, which is still coded as U07.1), post-COVID-19 syndrome, or historical COVID-19?
  • Do you believe this positive PCR test indicates acute COVID-19 infection, or is it a false positive?

When you compose your query, try to avoid using words from the coding lexicon that may confuse the provider. “Manifestation,” “principal diagnosis,” or “sequela of” may not elicit the clarification you are hoping for, because the provider may understand it differently from your intent.

As people who have been vaccinated have a very small chance of contracting COVID-19, but are likely to have mild disease if they do, this scenario of incidental COVID-19 may become a more common phenomenon. The providers and coders are going to have to know how to interpret the clinical situation.

The numbers are going in the right direction. We are also fortunate that the seasons have changed, and hopefulness is visible in dropped mandates. The pandemic is not over yet, however, and COVID-19 may become an endemic illness with periodic and/or localized epidemic swells. If you were considering vaccination but have concluded it’s not necessary, remember that the disease is as impactful to unvaccinated individuals as it ever was.

The only thing worse than you dying or suffering from post-acute-COVID-19 syndrome is you transmitting it to a loved one – in which case they could die or become a long-hauler.

Get vaccinated!

Programming Note: Listen to Dr. Erica Remer when she co-hosts Talk Ten Tuesdays with Chuck Buck, Tuesdays at 10 a.m. Eastern.

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