Topic: Pneumonia and COVID
H&P: 60 y/o male presented to ER after recent admission for COVID with worsening hypoxia, SOB, dry cough, and generalized weakness. Patient denies fever, weight loss, or night sweats. Patient denies chest pain.
Admitting Principal Diagnosis: COVID 19 pneumonia
PMH: HTN, BPH,CAD, non-smoker, No alcohol consumption, no exposure to asbestos.
Vitals: Initial: Temp 96.2, HR 88, RR 28, BP 170/72, 90% on room air when walking at least 10 feet. EKG shows afib with RVR.
Physical Exam: Resp: Slightly tachypneic with bilateral basilar crackles and decreased air entries at lung base.
Labs: WBC 7.4, no COVID test performed this admission, but documentation states that the patient had a positive COVID test during the admission 1 week prior. Serial HS Troponin: 26, 26, 32. UA + for bacteria, culture reveals no growth after 5 days. Creatinine 0.8 on admission. Lactic acid 2.4 on admission, 1.0 the following day.
Radiology: Chest x-ray findings state moderate bilateral pulmonary opacities compatible with multifocal infection or pulmonary edema.
Treatment: Decadron, Dextromethorphan (anti-tussive), vancomycin, cefepime. Patient given IV betablocker x2 for afib, received an IV fluid bolus of 500mL in the ER and is placed on 0.9%NS IV fluids at 80mL/hr once admitted.
Documentation: H&P states, “COVID pneumonia with superimposed healthcare acquired pneumonia, Decadron given in ER. Start vanc to cover possible HAP.” PN states, “Patient’s presentation consistent with COVID. Cont vanc. Dose of Decadron in ER, will monitor symptoms.”
Discharge Dx: Possible fibrosis, Post COVID pneumonia vs HAP.
Question: Are there query opportunities based on the scenario stated above?
There are two possible principal diagnoses in the record:
- Post COVID organizing pneumonia which would need to be clarified as an organizing pneumonia
- COVID pneumonia
Coding guidelines state that there are separate coding pathways for post COVID pneumonia and COVID organizing pneumonia:
COVID-19 associated pneumonia with negative COVID-19 test
ICD-10-CM/PCS Coding Clinic, First Quarter ICD-10 2021 Page 47
Therefore, when a patient presents with an acute manifestation of COVID-19, such as pneumonia, code U07.1 should be reported as the principal or first diagnosis, regardless of whether the patient’s most recent COVID-19 test is positive or negative.
Post COVID-19 organizing pneumonia
ICD-10-CM/PCS Coding Clinic, First Quarter ICD-10 2021 Page 48
Based on the documentation provided, the patient has an organizing pneumonia due to previous COVID-19 infection. Assign code J84.89, Other specified interstitial pulmonary diseases, followed by code B94.8. Sequelae of other specified infectious and parasitic diseases, for a diagnosis of post-COVID 19 organizing pneumonia.
- A query is needed to clarify whether the patient is being treated for post COVID organizing pneumonia or if the pneumonia is an acute manifestation of the COVID infection.
- A query for clarification as to whether a superimposed HAP was treated or ruled out. A query for clarification as to whether UTI was treated or ruled out based on documentation of a UTI with a negative urine culture.
- A query is needed for possible type 2 MI based on patients’ presentation with dyspnea, elevated troponin and afib with RVR and treatment for pneumonia.
- A query is needed for possible acidosis based on the lactic acid of 2.4. and 1.0.
Documentation without Clarification:
Principal Diagnosis: J8489 other specified pulmonary interstitial disease
Secondary Diagnoses: B948 Sequelae of other specified infectious and parasitic disease (prior to 10/1/21, new code is U09.9), J159 unspecified bacterial pneumonia, I10 Essential hypertension, I4891 atrial fibrillation, I2510 atherosclerotic heart disease of native coronary artery without angina pectoris, N390 Urinary tract infection
Working DRG: 196 INTERSTITIAL LUNG DISEASE WITH MCCRW: 0.7423 GLOS 2.4 SOI/ROM: 2/3
Documentation with Clarification:
Principal Diagnosis: U071 COVID 19
Secondary Diagnosis: J1282 Pneumonia due to coronavirus disease 2019, I10 Essential hypertension, I4891 atrial fibrillation, I2510 atherosclerotic heart disease of native coronary artery without angina pectoris, E872 acidosis, I21A1 Myocardial infarction type 2
Working DRG: 177 RESPIRATORY INFECTION AND INFLAMMATORY W/MCC RW: 1.8453 G LOS: 5.4 SOI/ROM: 3/3
CDI Educational Tips:
Without clarifying the type of pneumonia treated, the case may be susceptible to an audit since there is a significant reimbursement difference (based on difference in relative weight). In addition, the CDC and WHO is using coded data to capture the cases of COVID vs post COVID for research and data trends, making accuracy crucial to help further our understanding of how to treat COVID as well as the after effects.
This is a short synopsis of a possible patient record and is not intended to be all inclusive. This is for educational purposes only and not intended to replace your institutional guidelines.