Don’t query for every result.
There are many different ways we investigate infectious diseases with current technology. In the case of COVID-19, research labs might culture the living organism, the SARS-CoV-2 virus. The widely used Reverse Transcription Polymerase Chain Reaction (RT-PCR, or PCR) test qualitatively detects nucleic acid from the viral ribonucleic acid (RNA), requiring viral genetic material. There are now rapid antigen tests, which can detect fragments of proteins found on or within the virus. Finally, there are antibody, or serological, tests, which assess whether or not antibodies have been made in an immune response to the viral infection.
Each of these tests has its own accuracy, sensitivity, specificity, and challenges. Not all test results come back in a clinical timely fashion. We are having issues with availability of COVID-19 testing, nationally and globally. The Food and Drug Administration (FDA) has been issuing emergency use authorizations (EUAs) for tests at an unprecedented pace, but there are still many tests that have not been approved.
The tests to diagnose current COVID-19 infection have significant false negative rates. The PCR testing has up to 30 percent, and the rapid antigen testing is noted to have a 15-20-percent false negative rate. Some of these tests take hours, and some take days to yield results.
This means that patients will sometimes be discharged or die prior to the results of their COVID-19 tests being known. The American Hospital Association/American Health Information Management Association (AHA/AHIMA) guidance advises developing facility-specific coding guidelines to hold back coding of inpatient admissions and outpatient encounters until test results are available. They recommend querying the provider if the test results come back negative, even if the provider documented a diagnosis of COVID-19 on a clinical basis, to give them “the opportunity to reconsider the diagnosis based on the new information.”
In my opinion, as a physician and an ex-physician advisor, I can categorically assure you that it would irritate a provider to get queried to confirm a diagnosis they had already made clinically and documented in a codable format. I agree with developing facility-specific coding guidelines, but they should be sensible and reasonable.
Here are my suggestions:
Concordant documentation and testing (they match):
- “COVID-19 by clinical judgment” test returns positive: code without query. Send feedback notification informing the provider of a positive result. The provider may addend the record with the confirmatory result if they so choose.
- “Acute gastroenteritis. Doubt COVID-19” test returns negative: do not code COVID-19 (code symptoms and exposure). Do not query. Notification is not necessary, but could be done on an informational basis.
- “Fever and cough, probable COVID-19” test returns positive: code without query. Send confirmatory notification informing provider of positive result. The provider may addend the record with the confirmatory result if they so choose.
Discordant documentation and testing (they don’t match):
- “COVID-19 by clinical judgment” test returns negative:
- If clinical indicators are supportive, code without query. Send feedback notification informing provider of positive result. It would be best practice for them to document the negative result and explain that they think it is a false negative.
- If clinical indicators do not support diagnosis, generate a clinical validation query.
- “Acute gastroenteritis. Doubt COVID-19” test returns positive: code COVID-19. Send notification informing provider of positive result and request addendum for the record.
- “Fever and cough, probable COVID-19” test returns negative: query for clarification if they haven’t proactively addressed likelihood of false negative test result. Does the provider believe this is a false negative? Do they want to revise their diagnosis? Without a definitive diagnosis, this should be coded as signs and symptoms and Z20.828, the exposure code.
No mention of COVID-19 or testing in documentation, but testing done: this may ultimately result in denial of payment for the testing if there is no clearly identifiable justification for why the test was performed.
- If positive: code COVID-19. Send notification informing provider of positive result and request addendum for the record. This notification should educate that best practice is to always document a reason as to why COVID-19 testing is being done (e.g., due to potential exposure, patient request, etc.).
- If negative: send notification informing the provider that best practice is to always document a reason as to why COVID-19 testing is being done (e.g., due to potential exposure, patient request, etc.). Code exposure (since we are in pandemic situation).
Don’t query for every result. Providers will change their behavior if they understand why it is being asked of them, and if it isn’t an excessive encumbrance. They do not appreciate additional documentation burden for no good reason. Give them a good reason.
Example of verbiage for notification/request for addendum due to return of pending test results:
- If you believe this is a false negative, best practice would be to addend the medical record accordingly.
- If a negative result has made you reconsider the diagnosis, please addend the medical record and update your diagnosis.
□ You made an uncertain diagnosis of COVID-19, and the results are discordant.
One of our Talk Ten Tuesdays listeners shared with me that her facility uses a query when a COVID-19 test returns negative, but the provider documents that COVID-19 is still suspected in an uncodable format. I have made some minor tweaks:
Query for negative COVID-19 test results with uncertain COVID-19 documentation:
This patient presented with (include symptoms/conditions) and was worked up for COVID-19. Negative COVID-19 test results were acknowledged, and it is documented that COVID-19 is still suspected (uncertain diagnosis verbiage).
Based on clinical impression at the time of discharge, please select the most appropriate contributing etiology:
() COVID-19 (SARS-CoV-2), although testing was negative
() Possible COVID-19, uncertainty remains
() Other contributing organism (please specify)…
() Unable to clinically determine
() Other (please specify)…
Programming Note: Listen to Dr. Erica Remer every Tuesday on Talk Ten Tuesdays, 10-10:30 a.m. EST.