Cracking the Code
Historical vs Active COVID-19 Infection
History codes are reported when a physician’s documentation specifies that a patient no longer has a condition. There is not a particular timeframe for personal history conditions; if a patient is diagnosed with pneumonia but no longer has pneumonia during a follow-up visit, then a coder would assign a code for personal history of pneumonia. This same rule applies when reporting personal history of COVID-19. U07.1, positive COVID-19 is ONLY reported if documentation supports a confirmed diagnosis. If it is documented that the patient was positive for COVID-19 weeks ago but no longer has the condition during their current encounter, then the coding guidelines state that a personal history code should be reported.
Q: A patient who previously tested positive for COVID-19 is seen for a follow-up exam. The physician orders lab testing once again, and the results are now negative for COVID-19.
A: Z09, Encounter for follow-up examination after completed treatment for conditions other than malignant neoplasm
Z86.16, personal history of COVID-19
Z86.16, personal history of COVID-19
Reference: ICD-10-CM Official Guidelines for Coding and Reporting FY 2022 Section I.C.g.j.