Wednesday, April 29, 2020

The Coding and Counting COVID-19 Patients

There is so much information out there about COVID-19.  It can be confusing because so much of what we are told on a day-to-day basis about COVID-19 conflicts: Stay at home. We need to prevent the spread of this virus. Don’t stay at home.  We need to develop immunity. Wear a mask. Don’t wear a mask. Etc. Etc. Etc.

I cannot provide expert advice on the vast majority of this information. I do not have a medical degree and expertise regarding how to best treat COVID-19 patients. Nor do I know the best course of action regarding when the stay-at-home orders should be lifted and the economy re-opened.

I am an expert in the arena of Health Information Management (also known as H.I.M.), and important to COVID-19 because H.I.M. is the department/profession that houses medical coding.  Coding assigns diagnosis codes to the medical records of patients, which in turn generates data on the number of COVID-19 cases in the United States.  And with that data, the government, health officials and others make important decisions on our path forward. In the future, this data will be very important in research and the retrospective evaluation of COVID-19.

Because I am a Health Information Management professional, I want to clear up a few questions about how diagnosis codes are assigned to patients. I have heard conspiracy theories and questions about the counting of COVID-19 patients. Some say that the numbers are being padded. I have heard doctors are saying they are being “pressured” to add COVID-19 to the diagnosis list. These questions and concerns cannot be addressed until one understands how diagnosis coding works.  And many people – including doctors – do not understand how and when a diagnosis code is assigned to a patient’s medical chart.

First, a patient either has COVID-19 or he doesn’t. There are now COVID-19 tests that say “positive” (patient has COVID-19) or “negative” (patient does not have COVID-19). There have been questions about how accurate these laboratory tests are for COVID-19 – but that is another conversation and outside my area of expertise. If the laboratory test comes back positive, this means the patient has COVID-19 and this means that COVID-19 should be listed among the patient’s diagnoses in the medical documentation by the doctor.  And in turn, the diagnosis code of U07.1 (COVID-19) will be listed in the patient’s medical record and on the encounter. Think of “encounter” as an encounter with the health system – whether it is an inpatient stay in a hospital, a visit to the Emergency Room, appointment with family doctor, etc.

COVID-19 should never be excluded from a patient’s medical record if the patient has it.  Regardless of if the patient came to the hospital for another reason; even if he died of something else; even if the patient had other medical issues going on at that time which worsened his case of COVID-19.

everything that is abnormal with a patient should be listed in medical documentation. Because the medical professionals taking care of the patient need ALL the information in order to treat the patient effectively.  And should the patient return to the hospital again for the same or another reason, there needs to be continuity of care with that patient. This is how all medical documentation and coding works and has worked for a very long time. It is not different with coding for COVID-19. We will get to the how and in what order diagnosis codes are listed later on. But to wrap up my point, there is no “pressuring” to entice doctors to add COVID-19 to a patient chart. The patient either has COVID-19 or he doesn’t. Sure, if someone is pressuring doctors to add COVID-19 to a patient chart when the patient doesn’t have COVID-19, then that is a problem. But the vast majority of doctors would not deem it acceptable to enter false information into the medical chart. They could lose their medical license. Therefore, I can only assume that when a doctor says he is being “pressured” into adding COVID-19 to the diagnosis list – the patient(s) in question do actually have COVID-19 – but the doctor thinks that it is unimportant to the visit and/or he doesn’t think the patient should be “counted” as a COVID-19 patient for whatever reason. And therefore, he doesn’t want to add COVID-19 to the diagnosis list. But that isn’t his call.  That is not how medical documentation and coding works. The patient has COVID-19 or he doesn’t. It isn’t an “opinion” – unless there is some suspicion that the laboratory test is inaccurate. It is important to know how many patients do actually have COVID-19 – whether it contributes to the death rate or survival rate. Accurate data is important. And further, it is important to have the COVID-19 diagnosis in the patient’s medical record to ensure the safety of the patient’s caregivers – in the healthcare system and at home – so that they take the necessary precautions to protect themselves and others.

Now, onto how and in what order the diagnosis codes are listed. The “principal diagnosis” is always the reason that the patient was being seen or was admitted into the hospital. And the principal diagnosis does not change – regardless of what happens after the patient is admitted. For example, if a patient goes to the hospital because of a hip fracture, but then develops COVID-19 symptoms while at the hospital and a test confirms the he does have COVID-19 – the hip fracture is the principal diagnosis and COVID-19 will be among the other diagnoses listed (even if the COVID-19 actually causes the death of that patient or lengthens the hospital stay of the patient). Another example, a patient goes to Emergency Room with shortness of breath and cough, tests are run and confirm that these symptoms are because of COVID-19. The principal diagnosis will be listed as COVID-19 even if the patient falls off the hospital bed and breaks his hip while in the Emergency Room.

The reason for death is another matter. In order to determine the reason a patient actually died, one would need to look at the death certificate. The death certificate will list the “cause of death” (i.e. what diagnosis actually killed the patient) – regardless of the principal diagnosis or other diagnoses the patient may have had at the time of death. Now, there may be some room for discussion regarding how the “reason for death” is evaluated and determined, but that is not within the realm of Health Information Management nor coding.  A medical examiner who does autopsies for a living would have to chime in how the “reason for death” is assigned when there might be “co-morbidities.” A patient has co-morbidities when he has more than one chronic disease or conditions at the same time. And from current data, we know that co-morbidities can worsen or complicate a case of COVID-19.

Now, do we need to look at data from different directions? For example, how many patients died with a diagnosis of COVID-19 and had no other diagnoses? How many patients died with a diagnosis of COVID-19 and had other diagnoses (co-morbidities)?  How many patients have a principal diagnosis of COVID-19 (i.e. they entered the hospital because of COVID-19)? Yes, absolutely. But hopefully, I can at least clear up any questions on how and when a diagnosis of COVID-19 is assigned to a patient’s medical record.

About the Author

Since 2011, Lauren Manson, RHIA has been the Executive Director of the Ohio Health Information Management Association (OHIMA). Before taking on her role with OHIMA, Lauren worked in the H.I.M. department at The Ohio State University Medical Center and then spent several years implementing Electronic Medical Records throughout the United States. She graduated with honors from The Ohio State University in 2008 with a major in Health Information Management and Systems and a minor in Business. 


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