Updates Telemedicine Town Hall MSMS May 2020 Young Medical Consulting, LLC 1 Updates from Medicare on Coding & Billing for Telemedicine COVID-19 Jill Young, CEMC, CPC, CEDC, CIMC Young Medical Consulting, LLC East Lansing, Michigan 1 Disclaimer • This material is designed to offer basic information for coding and billing. The information presented here is based on the experience, training, and interpretation of the author. Although the information has been carefully researched and checked for accuracy and completeness, the instructor does not accept any responsibility or liability with regard to errors, omissions, misuse, or misinterpretation. This handout is intended as an educational a guide and should not be considered a legal/consulting opinion. • This information is current as of the date the lecture was written – • May 10, 2020 2
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Updates Telemedicine Town Hall MSMSMay 2020
Young Medical Consulting, LLC 1
Updates from Medicare on Coding & Billing for Telemedicine COVID-19
Jill Young, CEMC, CPC, CEDC, CIMC
Young Medical Consulting, LLC
East Lansing, Michigan
1
Disclaimer
• This material is designed to offer basic information for coding and billing. The information presented here is based on the experience, training, and interpretation of the author. Although the information has been carefully researched and checked for accuracy and completeness, the instructor does not accept any responsibility or liability with regard to errors, omissions, misuse, or misinterpretation. This handout is intended as an educational a guide and should not be considered a legal/consulting opinion.
• This information is current as of the date the lecture was written –
• CMS will be reprocessing claims paid prior to increase
3 May
CODE RVU STATUS CODE
99441 0.40 N
99442 0.78 N
99443 1.14 N
Not Payable By Medicare (3-20-20)
Corona Virus – COVID-19 vs Healthcare
• Presidential declaration of a disaster or emergency under the Stafford Act or National Emergencies Act and Declaration of a public health emergency by the HHS Secretary under Section 319 of the Public Health Service Act
• Waiver 1135 of Social Security Act(the ACT)
• Coronavirus Aid, Relief and Economic Security (CARES) Act• March 27, 2020
• Medicare and Medicaid Programs; Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency • CMS-1744-IFC (Interim final rule with comment period)• March 30, 2020
• Medicare and Medicaid Programs, Basic Health Program, and Exchanges; Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency and Delay of Certain Reporting Requirements for the Skilled Nursing Facility Quality Reporting Program
• CMS-5531-IFC (Interim final rule with comment period)• April 30, 2020
• CMS continues to release clarifying Q&A in several areas• FAQ Medicare Fee-for-Service (FFS) Billing (dated 5-1-20)
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Originating Site
• The location where a Medicare beneficiary gets physician or practitioner medical services through a telecommunications system.
• Eligible geographic areas include• Rural health professional shortage areas (HPSA)
• Counties not classified as a metropolitan statistical area (MSA)
• Federal telemedicine demonstration projects as of December 31, 2000• May serve as the originating site regardless of geographic location.
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Telemedicine – Originating Site Post CoVID-19
• May be any location patient is experiencing the encounter from• Home
• Nursing Home
• Daughter’s Home
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Telemedicine – Distance Site Practitioners
• Distant site practitioners who can furnish and get payment for covered telehealth services (subject to State law) are: • Physicians
• Nurse practitioners (NPs)
• Physician assistants (PAs)
• Nurse-midwives
• Clinical nurse specialists (CNSs)
• Certified registered nurse anesthetists
• Clinical psychologists (CPs) and clinical social workers (CSWs) CPs and CSWs cannot bill Medicare for psychiatric diagnostic interview examinations with medical services or medical evaluation and management services. They cannot bill or get paid for Current Procedural Terminology (CPT) codes 90792, 90833, 90836, and 90838.
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Place of Service
Office - 11
• Some codes refer to “usual place” of service billed from
• Office
Telehealth - 02
• Location services are provided or received through a telecommunication system
• CMS/Medicare• Payment is reduced to allow for
originating site fee paid to facility
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Modifiers
Modifier - GT
• Via interactive audio and video telecommunications systems.
Modifier - 95
• Synchronous Telemedicine Service rendered via a realtimeinteractive Audio and Video Telecommunications system
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Interactive Telecommunications System Definition Final Rule
• Multimedia communications equipment that includes, at a minimum • Audio and video(A/V) equipment permitting two-way, real-time
interactive communication between the patient and distant site physician or practitioner
• Audio/visual real time telecommunication technology
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Telemedicine Services Added During PHE
• Emergency Department Visits
• Observation code series (admit and discharge)
• Initial Hospital Care Visits
• Nursing Facility Visits
• Domiciliary, Rest Home, or Custodial Care Services
• Home Visits
• Inpatient Neonatal and Pediatric Critical Care Visits
G0420 Ed svc ckd ind per session G2086 Off base opioid tx 70min
G0421 Ed svc ckd grp per session G2087 Off base opioid tx, 60 m
G0425 Inpt/ed teleconsult30 G2088 Off base opioid tx, add30
G0426 Inpt/ed teleconsult50 G9685 Acute nursing facility care
G0427 Inpt/ed teleconsult70
G0436 Tobacco-use counsel 3-10 min
G0437 Tobacco-use counsel>10min
G0438 Ppps, initial visit
G0439 Ppps, subseq visit
G0442 Annual alcohol screen 15 min
G0443 Brief alcohol misuse counsel
G0444 Depression screen annual
G0445 High inten beh couns std 30m
G0446 Intens behave ther cardio dx
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TELEMEDICINE – State of Michigan
• Expanded access to telemedicine by immediately allowing Medicaid beneficiaries to receive services in their home while the state combats COVID-19.
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Example of Grid Unique to your practice
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**Information in grid is incomplete*****
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Variables – 1st Group
• Is contact Patient Initiated• Patients would contact office regarding need for care (with a problem)
• Patient has an appointment for continuing management of their chronic illness
• Method of contact• Electronic
• Telephone
• Qualifiers• Within 7 days of related E/M performed prior
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Variables – 2nd Group
• Providers method of reply• Electronic• Telephone• Telephone and audio
• Recommendation for follow up E&M or Procedure within 24 hrs
• Level of service
• What Insurance?
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Documentation
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Time
• Documentation of time on Telehealth codes is not defined in most instances• Recommendation – document total time spent
• Shows you met requirement of code
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1995 E&M Guidelines
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You may use time for your E&M services
99213- 15 minutes
99214 – 25 minutes
Traditional E&M documentation (use History and MDM)
99213 – HPI – 1 99214 – HPI – 4
ROS – 1 (pertinent to problem) ROS – 2+
PFSH (none required) PFSH – 2
MDM – Low MDM - Moderate
Telemedicine – Office ONLY
• Office/outpatient E/M level selection for services when furnished via telehealth can be based on MDM or time*• Use current definition of MDM
• This removed any requirements regarding documentation of history and/or physical exam in the medical record• Clinically appropriate history and exam should still be performed
• This is a policy revision on an interim basis, only• Policy similar to policy beginning in 2021
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Telemedicine – Office ONLY (99201-99215) “NEW” Time*
• Time* defined as all of the time associated with the E/M on the day of the encounter• Time personally spent by the reporting provider
• Including face-to-face and non face-to-face time
• Also true for primary care exception
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Telemedicine – Office ONLY (99201-99215)
• Typical Times referenced in prior waiver were not the correct
• Finalized, typical times for office outpatient E&M are times listed in CPT code descriptor
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CPT CODETYPICAL
TIME
New
Patient
99201 10
99202 20
99203 30
99204 45
99205 60
Established
Patient
99212 10
99213 15
99214 25
99215 40May
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Teaching Physician
For the duration of the PHE for the COVID-19 pandemic
Teaching physician may:
Not only direct the care furnished by residents
But also review the services provided with the resident, during or immediately after the visit, remotely through virtual means
via audio/video real time communications technology
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Teaching Physician
• Validated that the following additional services when furnished by a resident under primary care exception• 99441-99443 – Telephone E&M
• 99495-99496 - Transitional Care Management
• 99421-99423 - Online Digital E&M
• 99452 - Telehealth referral services
• Also validated that when selecting the level of E&M, residents may use 2021 model with MDM or Time* (new time)
34 May
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Telemedicine – Diagnoses Allowed
• Telehealth provision allows care without regard to the diagnosis of the patient
• Prevent vulnerable beneficiaries from unnecessarily entering health care facility when needs can be met remotely
• Example cited, patient needing a visit with physician for refill of medication
• Services must still be reasonable and necessary
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New Code effective April 1, 2020
• Chapter 22
• Codes for special purposes (U00-U85)
• Provisional assignment of new diseases of uncertain etiology or emergency use (U00-U49)
• Note: Codes U00-U49 are to be used by WHO for the provisional assignment of new diseases of uncertain etiology.
• U07 Emergency Use of U07
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New Code effective April 1, 2020
• U07.1 - COVID-19
• Use additional code to identify pneumonia or other manifestations.
• Patients with pneumonia, case confirmed as due to the 2019 novel coronavirus (COVID-19), assign • J12.89 - Other viral pneumonia
• AND
• B97.29 - Other coronavirus as the cause of diseases classified elsewhere
April 1, 2020 to
September 30, 2020
• Patients with pneumonia confirmed as due to the 2019 novel coronavirus (COVID-19) assign• U07.1 – COVID-19
• AND
• J12.89 - Other viral pneumonia.
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Testing No Signs or Symptoms No Exposure
• Patients who are asymptomatic who are being screened for COVID-19 and have no known exposure to the virus, and the test results are either unknown or negative, assign• Z11.59 - Encounter for screening for other viral diseases
• Eff April 1st
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Supervision
• Use of real-time, audio and video telecommunications technology allows for a billing practitioner to observe the patient interacting with or responding to the in-person clinical staff through virtual means, and thus, their availability to furnish assistance and direction could be met without requiring the physician’s physical presence in that location• Mostly NP/PA
• The presence of the physician includes virtual presence through audio/video real-time communications technology when use of such technology is indicated to reduce exposure risks for the beneficiary or health care provider• Mostly Auxiliary staff
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General Supervision
• Procedure is furnished under the physician’s overall direction and control but the physicians presence is not required during the performance of the procedure
• May also include a virtual presence through the use of telecommunications technology• Noted that even in the absence of the PHE general supervision could be
conducted virtually• Such as audio only telephone or text messaging
44May
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Teaching Physician Direct Supervision
• The requirement for the presence of a teaching physician can be met• At a minimum, through direct supervision by audio/video real-time
communications technology
• For duration of the PHE for the COVID-19 pandemic• Teaching physician may not only direct the care furnished by residents, but
also review the services provided with the resident, during or immediately after the visit• Remotely through virtual means via audio/video real time communications technology
45May
Pharmacists
• During PHE pharmacists fall within definition of auxiliary personnel
• May provide incident to billable (by Physician or NPP) services• With appropriate level of supervision
• If payment for services not included in Medicare Part D Benefit
• Must still be within state scope of practice and state law
46 May
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Supervision of Diagnostic Test
• Level of supervision required to be done by a physician• NOT ALLOWED SUPERVISION BY
• Nurse Practitioner
• Physician Assistant
• Clinical Nurse Specialist
• Certified Nurse Midwife
• During PHE• All above may provide the appropriate level of supervision assigned to
diagnostic tests
47 May
Remote Physiological Monitoring
• Remote monitoring of physiologic parameter(s)(e.g., weight, blood pressure, pulse oximetry, respiratory flow rate)• 99453 - Initial; set-up and patient education on use of equipment• 99454 - Device(s) supply with daily recording(s) or programmed alert(s)
transmission, each 30 days
• Remote physiologic monitoring treatment management services, clinical staff/physician/other qualified health care professional time in a calendar month requiring interactive communication with the patient/caregiver during the month• 99457 - First 20 minutes • 99458 - Each additional 20 minutes
48 May
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Remote Physiological Monitoring
• 99473 - Self-measured blood pressure using a device validated for clinical accuracy; patient education/training and device calibration
• 99474 - Separate self- measurements of two readings one minute apart, twice daily over a 30-day period (minimum of 12 readings), collection of data reported by the patient and/or caregiver to the physician or other qualified health care professional, with report of average systolic and diastolic pressures and subsequent communication of a treatment plan to the patient
49 May
Remote Physiological Monitoring
• Combination of permanent and interim policies allow RPM services • New and Established patients
• Consent obtained at time of service• Furnished by auxiliary personnel
• Direct supervision• May be met virtually through audio/video real-time communications technology
• Patient can be checked-in• Nurses or other auxiliary personnel, working with physicians
• Medical devices are defined on the FDA website
50 May
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Remote Physiological Monitoring
• Policy established on interim final basis for the duration of the COVID-19 PHE to allow RPM monitoring services to be reported to Medicare • For periods of time that are fewer than 16 days of 30 days
BUT
• No less than 2 days
• As long as the other requirements for billing the code are
• No alteration in codes 99454, 99453, 99091, 99457, and 99458 • Overall resource costs for long-term monitoring for chronic conditions
51 May
Remote Physiological Monitoring
• Codes 99454, 99453, 99091, 99457, and 99458
• If Monitoring lasting fewer than 16 days, but no less than 2 days • Limited to patients who have a suspected or confirmed diagnosis of COVID-19
• Ordinarily an initiating visit is required• May be satisfied via telehealth visit
• Patients may be new or established
•
52 May
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CoVID- 19 Specimen Collection
• No code identified to describe the services that would be furnished in the context of large-scale dedicated testing operations• Specifically, assessment of COVID-19 symptoms and exposure
AND
• Specimen collection for new patients
53 May
CoVID- 19 Specimen Collection
• 99211 - Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician or other qualified health care professional• Typically does not involve interaction with physician or other qualified health
care professional
• Presenting problem(s) are minimal
• Typically is reported by a physician or practitioner when the patient only sees clinical office staff for services like acquiring a routine specimen sample
54 May
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CoVID-19 Specimen Collection
• For duration of the PHE• 99211 will be recognized for both New and Established patients
• For both physicians and NPPs
• On an interim basis - 99211• When clinical staff assess symptoms and collect specimens for purposes of
COVID-19 testing • New and Established Patients• Physicians and NPPs’ (incident to services)
• Cost-sharing for this service will be waived when all other requirements under section 6002(a) of the Families First Coronavirus Response Act are met
55 May
CoVID-19 - Specimen Collection
• G2023 - Specimen collection for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), any specimen source) • Used for collection by an independent lab
• C9803 - Hospital outpatient clinic visit specimen collection for severe acute respiratory syndrome coronavirus 2 [SARS-COV-2] [coronavirus disease (COVID-19)], any specimen source)• Under the OPPS for hospital outpatient departments (HOPDs) to bill for a
clinic visit dedicated to specimen collection
56 May
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Store & Forward - G2010Virtual Check in – G2012• New patients and established patients allowed
• Both codes may be billed on the same date of service• Same practitioner
• Same patient
57 May
Expansion of Providers
• During the PHE the availability of codes G2010 and G2012 is broadened to allow certain practitioners who do not report E&M codes to bill for these services• Physical Therapists
• Occupational therapists
• Speech language pathologist
• Licensed clinical social workers
• Clinical psychologists
58 May
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Patient Initiated
• “we expect that these services would be initiated by the patient, especially since many beneficiaries would be financially liable for sharing in the coast of these services.”
• This means that the patient must consent to the service before or at the same time it take place and does not prohibit practitioners from educating on their own initiative beneficiaries on the availability of the service prior
• CMS Open Forum Call : No physician Cold Calls
59 May
Initiated by Patient
• CMS NEWS RELEASE
• "We expect that these virtual services will be initiated by the patient; however, practitioners may need to educate beneficiaries on the availability of the service prior to patient initiation".
• Patients would contact office regarding need for care (with a problem).
• I see this education of beneficiaries to mean the patient would need to be told of the option of the various types of Telehealth services
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Homebound Definition
• Practitioner has determined it is medically contraindicated for them to leave home• Suspected or confirmed diagnosis of CoVID-19
• The patient has a condition making the patient more susceptible to contracting• Medically contraindicated
61 May
Home Health - Allowed Practitioners
• In addition to physicians an allowed practitioner may • Certify
• Establish
• Periodically revised the plan of care as well as supervise the provision of its items and services under home health benefit
• Amending regulations “Allowed Practitioners” to include• Nurse practitioners
• Certified Nurse Specialists
• Physician Assistants
62 May
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Important Outstanding Question???
• We also note that clinical staff are “auxiliary personnel.” According to the 2019 CPT Codebook (p. xii), “A clinical staff member is a person who works under the supervision of a physician or other qualified health care professional and who is allowed by law, regulation, and facility policy to perform or assist in the performance of a specified professional service, but who does not individually report that professional service.”
• FAQ 5/1 page 31 question 21
68 May
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Non-Face-To-Face Services – Telephone Services (Physician or Other QHCP)
• Telephone evaluation and management service provided by a physicianor other qualified health care professional who may report evaluation and management services provided to an established patient, parent, or guardian not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; • 99441 - 5-10 minutes of medical discussion
• 99442 - 11-20 minutes of medical discussion
• 99443 - 21-30 minutes of medical discussion
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THANK YOU ! !
And now it is time for your questions
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ICD-10 Codes
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Code Only Confirmed Cases Eff 4/1/2020
• Code only a confirmed diagnosis of the 2019 novel coronavirus disease (COVID-19) as documented by the provider• Documentation of a positive COVID-19 test result
• Presumptive positive COVID-19 test result
This is an exception to the hospital inpatient guideline Section II
• For a confirmed diagnosis, assign code U07.1, COVID-19• In this context, “confirmation” does not require documentation of the type of
test performed
• The provider’s documentation that the individual has COVID-19 is sufficient.
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Presumptive Positive Eff 4/1/2020
• These should be coded as confirmed
• A presumptive positive test result means an individual has tested positive for the virus at a local or state level• Not yet been confirmed by the Centers for Disease Control and Prevention
(CDC)
• CDC confirmation of local and state tests for COVID-19 is no longer required
COCID-19 Sequencing Eff 4/1/2020
• When COVID-19 meets the definition of principal diagnosis use code U07.1, COVID-19• Sequenced first
• Followed by the appropriate codes for associated manifestations• Except in the case of obstetrics patients
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ICD-10-CM Coding Pneumonia
February 20, 2020 to
March 31, 2020
• Patients with pneumonia, case confirmed as due to the 2019 novel coronavirus (COVID-19), assign • J12.89 - Other viral pneumonia
• AND
• B97.29 - Other coronavirus as the cause of diseases classified elsewhere
April 1, 2020 to
September 30, 2020
• Patients with pneumonia confirmed as due to the 2019 novel coronavirus (COVID-19)assign• U07.1 – COVID-19
• AND
• J12.89 - Other viral pneumonia.
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ICD-10-CM Coding Acute BronchitisFebruary 20, 2020 to
March 31, 2020
• Patients with acute bronchitis confirmed as due to COVID-19, assign • J20.8 - Acute bronchitis due to
other specified organisms
AND
• B97.29 - Other coronavirus as the cause of diseases classified elsewhere
April 1, 2020 to
September 30, 2020
• Patients with acute bronchitis confirmed as due to COVID-19, assign• U07.1 – COVID-19
AND
• J20.8 - Acute bronchitis due to other specified organisms.
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ICD-10-CM Coding Bronchitis not otherwise specified (NOS)
February 20, 2020 to
March 31, 2020
Patients with bronchitis (NOS) due to the COVID-19, assign
• J40 - Bronchitis, not specified as acute or chronic
AND
• B97.29 -Other coronavirus as the cause of diseases classified elsewhere
April 1, 2020 to
September 30, 2020
• Patients with Bronchitis not otherwise specified (NOS) due to COVID-19 assign• U07.1 – COVID-19
AND
• J40, Bronchitis, not specified as acute or chronic.
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ICD-10-CM CodingLower Respiratory InfectionFebruary 20, 2020 to
March 31, 2020Respiratory Infection • Patients with COVID-19
documented as being associated with a lower respiratory infection, not otherwise specified (NOS), or an acute respiratory infection, NOS, assign• J22 - Unspecified acute lower
respiratory infectionAND
• B97.29 - Other coronavirus as the cause of diseases classified elsewhere
April 1, 2020 to
September 30, 2020
• Patients with COVID-19 documented as being associated with a lower respiratory infection, not otherwise specified (NOS), or an acute respiratory infection, NOS assign• U07.1 – COVID-19
• Patients with ARDS due to COVID-19, assign• J80 - Acute respiratory distress
syndromeAND
• B97.29 - Other coronavirus as the cause of diseases classified elsewhere
April 1, 2020 to
September 30, 2020
• Patients with acute respiratory distress syndrome (ARDS) due to COVID-19, assign• U07.1 – COVID-19
AND
• J80 - Acute respiratory distress syndrome
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ICD-10-CM CodingExposure to COVID-19
February 20, 2020 to
March 31, 2020
• Patients where there is a concern about a possible exposure to COVID-19, but this is ruled out after evaluation, assign• Z03.818 - Encounter for
observation for suspected exposure to other biological agents ruled out
April 1, 2020 to September 30, 2020
• Patients where there is a concern about a possible exposure to COVID-19, but this is ruled out after evaluation, assign
• Z03.818 - Encounter for observation for suspected exposure to other biological agents ruled out
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ICD-10-CM CodingExposure to COVID-19
February 20, 2020 to
March 31, 2020
• Patients where there is an actual exposure to someone who is confirmed to have COVID-19, assign• Z20.828 - Contact with and
(suspected) exposure to other viral communicable diseases
April 1, 2020 to
September 30, 2020• Patients where there is an actual
exposure to someone who is confirmed or suspected (not ruled out) to have COVID-19, and the exposed individual either tests negative or the test results are unknown, assign • Z20.828, Contact with and (suspected)
exposure to other viral communicable diseases.
• If the exposed individual tests positive for the COVID-19 virus, see guideline
(starting slide 7 )
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ICD-10-CM CodingScreeningFebruary 20, 2020
to March 31, 2020
April 1, 2020
to September 30, 2020
• Patients who are asymptomatic who are being screened for COVID-19 and have no known exposure to the virus, and the test results are either unknown or negative, assign• Z11.59 - Encounter for screening