Q&A: Preparing for COVID-19 documentation errors

Q: We are seeing an influx of possible COVID-19 patients at our facility. How can we prepare to query for COVID-19-related documentation and coding issues that are bound to come our way due to the newness of the diagnosis?

A: CDI and coding professionals can use the mnemonic M.U.S.I.C. as a model for record reviews to identify potential COVID-19-related documentation and coding issues and to formulate queries when encountering incomplete, imprecise, or unclear documentation. 

This model may be useful as it drills through layers of “due to,” “caused by,” and “demonstrated by,” addressed in physician queries.

The M.U.S.I.C mnemonic, outlined below, can be used as a foundation for critical thinking when determining the correct documentation and ICD-10-CM coding for the COVID-19:

• Manifestations: What are the signs and symptoms indicative of the COVID-19 illness?
  • These may include fever, cough, shortness of breath, or even hypoxemia, respiratory distress, or signs and symptoms commonly associated with sepsis.
• Underlying cause: What is the pathological origin of the illness?
  • Is it the COVID-19, another infectious cause, asthma, or another disease process?  
• Severity or specificity: Specify whether reportable conditions are acute or chronic, when applicable.
  • While any coronavirus (CoV) infections vary in the severity of illness they cause, their manifestations are invariably acute.
  • If a physician documents the presence of a CoV infection, it is COVID-19 or another specified virus? According to the Centers for Disease Control and Prevention (CDC), COVID-19 is a beta CoV like the Middle East respiratory syndrome CoV (MERS-CoV) and the severe acute respiratory syndrome CoV (SARS-CoV), both of which have their origins in bats. COVID-19 is a new CoV strain that had not been previously identified in humans. 
• Instigating or precipitating cause of the illness
  • Animal CoVs can infect people and then spread from person to person, according to the CDC.
  • Travel to or from an endemic area is a key history to obtain.
• Consequences of the infection, such as:
  • Acute respiratory failure.
  • Acute respiratory distress syndrome.
  • Myocardial injury (manifested by an elevated troponin) that would represent a form of viral myocarditis.
  • Sepsis without acute organ dysfunction due to a viral illness, if one subscribes to a Sepsis-2 definition of sepsis.
  • Superimposed bacterial pneumonia, such as one suspected to be due to staphylococcus aureus.
  • Viral pneumonia or bronchitis, usually manifested by an abnormal chest x-ray.

Providers should also consider severe sepsis as a mechanism for the acute nonpulmonary organ dysfunction or failure and pay close attention to any lactate elevations representative of septic or distributive shock in accordance with the Surviving Sepsis guidelines, published by the Society of Critical Care Medicine.

Note that since both the Society of Critical Care Medicine and the World Health Organization’s ICD-11 use Sepsis-3 criteria in making the diagnosis, to properly report Sepsis-3 sepsis in ICD-10-CM, the provider must explicitly document the term “severe sepsis” or explicitly document that any acute organ dysfunction is due to sepsis.

Editor’s note: This Q&A originally appeared in Revenue Cycle Advisor and was answered by James S. Kennedy, MD, CCS, CCDS, CDIP, founder and president of CDIMD, a Nashville-based physician and facility advisory and consulting firm. ACDIS CDI Education Specialist Dawn Valdez, RN, LNC, CDIP, CCDS, recently wrote a CDI COVID-19 Survival Toolkit. It is available for free in the ACDIS Resource Library. Click here to download it today.