Twice a year, in March and September, the Centers for Medicare & Medicaid Services (CMS) ICD-10 Coordination and Maintenance (C&M) Committee meets, and the public is encouraged to participate. I personally find it extremely rewarding. I feel like I am contributing to the evolution of the ICD-10-CM code set. I had aspired to attend in person this year, but COVID-19 happened.
On April 1, 2020, we were given new code U07.1, COVID-19, in an unprecedentedly rapid implementation. On Sept. 9, ICD-10-CM C&M meeting attendees were elated to discuss multiple proposed codes that will help us codify and classify COVID-19. These new COVID-19-related codes are earmarked for implementation by January 2021, and the deadline for comments is Oct. 9.
Multisystem inflammatory syndrome, or MIS, is a hyper-inflammatory condition being seen with past or present COVID-19 patients. It was initially noted in the pediatric population, but it has been seen in adults as well. It shares clinical features with Kawasaki disease, sepsis, and toxic shock syndrome. The current Centers for Disease Control and Prevention (CDC) case definition includes symptoms of fever, laboratory markers of inflammation, and severe illness requiring hospitalization, with at least two organ systems involved and laboratory evidence of SARS-CoV-2 (or suspected exposure).
Currently, the coding instruction is to use M35.8, Other specified systemic involvement of connective tissue, to signify MIS-C (-C for indicating its presence in children). The proposal is to create a new code, M35.81, Multisystem inflammatory syndrome. There are instructions to “code first” U07.1, COVID-19, for patients who currently have coronavirus infection, or to “code also,” if applicable, Z20.822, the new code being proposed to indicate exposure to SARS-CoV-2. Additional codes for associated complications like acute respiratory distress syndrome (ARDS) or acute myocarditis are recommended as well.
If you have comments, type them up and email them to nchsicd10CM@cdc.gov. The CDC reviews all comments and takes them into consideration. My comments about MIS were:
- In addition to U07.1 and Z20.822, I would add B94.8, Sequelae of other specified infectious and parasitic diseases, and the newly proposed Z86.16, Personal history of COVID-19, as potential additional codes. Since the CDC is not creating a unique specific sequela of the COVID-19 code, one would need both codes to signify that there is a sequela, and that it is from COVID-19.
- I’d also suggest making these examples, as opposed to exhaustive. MIS may seem to be linked to COVID-19 at this time, but in the future, there may be other viral illnesses that manifest with this condition. I think we should be proactive when we are updating and revising the ICD-10 code set. For the record, I really hope there is no “COVID-24” – or any other COVID, for that matter!
We also discussed other codes that will be especially useful and will greatly enhance the ability to perform tracking, trending, and analysis with regard to COVID-19:
- Z20.822, Contact with and (suspected) exposure to COVID-19, will supplant Z20.828, Contact with and (suspected) exposure to other viral communicable diseases. Z20.828 is the code we use to justify the medical necessity for all testing at this time, during the global pandemic.
- Z86.16, Personal history of COVID-19, will register a patient having had the illness previously. This will be easy for folks who have had a respiratory or other type of illness that elicited intercurrent molecular testing (either viral genetic or antigen). Will providers feel comfortable affixing this code to patients who had a suggestive illness, but no testing or a false negative? What about people with exposure who remained asymptomatic, but had a positive serological antibody test? As always, the coding will be dependent on the provider documentation.
This will need to be used with B94.8, Sequelae of other specified infectious and parasitic diseases. There’s also a sequela of a previous disease, which logically leads to the question: what was the previous disease? Ah, COVID-19, Z86.16.
- Z11.52, Encounter for screening for COVID-19, is particularly welcomed. I have always found it disconcerting to advise people to use only Z20.828 as the medical justification for testing an asymptomatic person. Even though everyone has potential exposure during a pandemic, I’m not sure it really equates to “contact with or suspected exposure to.” We will have to see what the American Hospital Association/American Health Information Management Association (AHA/AHIMA) official guidance is, but here is my opinion:
Screening is done for population health management. It is prospectively determined testing of a population of asymptomatic people to try to detect potential health disorders or diseases, to be able to treat or mitigate the condition early. When testing is undertaken routinely, without any significant prevalence or expectation of COVID-19 in the population, I would be comfortable using Z11.52. Examples would be preoperative testing; random, scheduled testing of long-term care facilities; and routine testing of student classes.
I would probably recommend that there be a pre-testing questionnaire, asking first, “do you have any known or suspected exposure?” If the patient answers affirmatively, I would use Z20.822, even if the “screening” were already planned. If the answer was negative, I would use Z11.52 without compunction.
If a population were to have COVID-19 found circulating in its midst, then reactive testing would no longer be screening, but Z20.822 (e.g., a nursing home that has two infected, symptomatic patients now tests all residents again for cause).
However, if an asymptomatic individual self-refers, that is, presents to be tested of their own volition, without community mandate or provider request, a screening code would also not be appropriate. If the patient has a concern that they might have been exposed and want to rule out COVID-19 , Z20.822 will be the appropriate code. If they do not have any known or suspected exposure, and do not work, live, or travel in a surge hot spot, but are merely curious, if the test is negative, Z03.818, Encounter for observation for suspected exposure to other biological agents ruled out, would be appropriate. During the pandemic, the official advice is to not use Z03.818, but Z20.828 (Z20.822, when it becomes available), even if there is no known or suspected exposure.
- J12.82, Pneumonia due to coronavirus disease 2019, was presented late in the day, and we really didn’t have adequate time for discussion, so there is great need for comments. My comments were:
- I prefer the title of the code mirror J12.81, Pneumonia due to SARS-associated coronavirus. One of the inclusion terms was “pneumonia due to 2019 novel coronavirus (SARS-CoV-2),” and I think that would be a better title for the code.
- I believe there should be a “code first” U07.1, COVID-19, instruction. It seems like it might be duplicative or redundant, but pneumonia may not be the sole manifestation of COVID-19 in this patient. Perhaps they have viral enteritis, anosmia, or “COVID toes.” All the manifestations should be captured and related to one another. COVID-19-associated pneumonia is only one of the manifestations.
We ran out of time before we could discuss Z71.85, Encounter for immunization safety counseling. Looking ahead to the day when there is a safe and effective SARS-CoV-2 vaccine, providers will need to discuss it with their patients or family members. Especially if there is reluctance, there may be a significant amount of time expended on this critical discussion. I am supportive of this code. It can be used with Z23, Encounter for (any – my word, not part of the title) immunization or Z28, Immunization not carried out and under-immunization status.
Go online to https://www.cdc.gov/nchs/data/icd/Topic-packet-September-8-9.2020.pdf to see all the proposals. The instructions to give comments are on page 11, and I encourage you do so. Join me in being part of the process!
Programming Note: Dr. Remer co-hosts Talk Ten Tuesdays with Chuck Buck every Tuesday at 10 a.m. EST.