Follow best practices for COVID-19 documentation and coding

Friday, April 3, 2020

As healthcare organizations battle the novel coronavirus (COVID-19) pandemic, patients, providers, and public health organizations need specific, accurate data. But in increasingly high-pressure, stressful situations, clinical staff have little time to spare to navigate complex guidelines and respond to multiple queries. Simple documentation guidelines and effective EHR interfaces will go a long way to easing the burden while ensuring documentation and coding remain correct and compliant.

Keep staff up to date on the latest clinical guidelines and reduce reliance on your EHR’s free text field to keep documentation clear and accurate, recommends Jay Anders, MD, chief medical officer of Medicomp Systems in Chantilly, Virginia. Accurate, clear documentation will support correct coding of COVID-19 infections and related conditions and cut down on the need to query clinical staff that will already be stretched thin.

One way to accomplish this is to limit use of and reliance on the EHR’s free text field, Anders recommends. Documentation in free text fields can sometimes mask critical information. It can also be difficult to enforce documentation standards when free text is used. Encourage clinical staff to be clear, succinct, and decisive in their documentation. Consider mobilizing IT and the EHR steering committee to work with the EHR vendor to implement specific forms and options to ensure documentation is streamlined and robust.

“Free text is the black hole of EHRs. It’s very difficult to extract information out of it that’s accurate and relatable without reading it as a physician. [Right now, organizations] need to be very succinct as to what or how they want their physicians and care providers documenting,” Anders says. “There are key questions that need to be asked so they can be coded and tracked. You fill out a form, either electronic or otherwise, that allows you to collect the information that you absolutely need to collect.”

Starting April 1, organizations will report COVID-19 infections using ICD-10-CM code U07.1 (2019-nCoV acute respiratory disease). Physicians don’t need a positive test result to diagnose a patient with a COVID-19 infection but they do need to be clear and decisive. If a COVID-19 infection is documented as “probable” it will be coded as Z20.828 (contact with and [suspected] exposure to other viral communicable diseases) or Z03.818 (encounter for observation for suspected exposure to other biological agents ruled out).

When testing is available, organizations must assign one of three codes depending on the type of test kit used. For the CDC test, use HCPCS code U0001 (CDC 2019-nCoV real-time RT-PCR diagnostic panel). For non-CDC test kits, laboratories must use either:

  • HCPCS code U0002 (2019-nCoV coronavirus, SARS-CoV-2/2019-nCoV (COVID-19), any technique, multiple types or subtypes [includes all targets], non-CDC); or
  • CPT® code 87635 (infectious agent detection by nucleic acid [DNA or RNA]; severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2] [COVID-19), amplified probe technique)

If a laboratory uses a non-CDC test that uses the method specified by CPT code 87635 but has not yet been able to implement the code in the billing system, the laboratory may use HCPCS code U0002.

Although a positive test isn’t required for a diagnosis, test results need to be entered in the EHR in a timely manner to ensure they’re available to clinical and revenue cycle staff. Depending on the EHR systems involved, this can be a challenge and a potential weak spot that could create significant ripple effects, Anders says.

For example, a patient with flu-like symptoms and a history of recent travel is diagnosed by her primary care physician (PCP) with a COVID-19 infection. A non-CDC test is performed and the results are negative. Several days after receiving the test results, the patient’s symptoms are worse. The patient contacts an urgent care center owned and operated by a local health system. If the urgent care physician is not able to access information from the patient’s PCP or crucial diagnostic and testing data is missing or difficult to find, that may send the urgent care physician down the wrong path.

Obtaining complete, clear, and accurate documentation will be critical to making diagnostic and treatment decisions – as well as for reporting to public health authorities, Anders explains.

“That’s what the big push is: Where are the cases and how are they getting reported? It’s all flowing from hospitals to local public health departments, to state public health departments to the CDC,” he says. “There are a lot of layers in the process. So, it’s imperative that the same code get recorded and transmitted throughout the entire loop.”

Editor's note: To talk to your peers about COVID-19 implications, visit the NAHRI Forums (for members only; log in with your username and password) or HCPro Forums (free forum membership). Please reach out to NAHRI Director Jaclyn Fitzgerald at with suggestions on how we can best meet your needs during this time. Visit the HCPro Coronavirus Response Solutions Center for a comprehensive list of training and education solutions. 

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