Q&A: Coding COVID-19 without a definitive lab test

Q: Can we code COVID-19 in the absence of a definitive lab test, if the physician documents the diagnosis?

A: Clinicians are capable of using their clinical judgment to clinically diagnose COVID-19. If the clinical indicators are consistent, code it (as documented). If there is a question of clinical validity, query.

Thirty percent of patients with COVID-19 may have a false negative test, so don’t let a negative result deter you if the clinical indicators are supportive. If the provider documents an uncertain diagnosis, code signs/symptoms/manifestations and Z20.828, Contact with and (suspected) exposure to other viral communicable diseases.

A positive result is considered reliable. It is recommended to hold the inpatient bill until pending results return unless the provider has made a clinical diagnosis of COVID-19. If the results return positive, the patient has COVID-19, and it is compliant to code it. If they used an uncertain diagnosis and the results return negative, a query may be considered.

Editor’s note: Laurie L. Prescott, MSN, RN, CCDS, CCDS-O, CDIP, CRC, CDI education director for HCPro in Middleton, Massachusetts, and Erica Remer, MD, FACEP, CCDS, president and founder of Erica Remer, MD, Inc. answered this question. They are both members of the ACDIS Advisory Board. Find out more about the board here.