Cracking the Code

Historical Versus Active COVID 19 Codes

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
Reference: Z86.19, personal history of other infectious and parasitic diseases https://www.aha.org/fact-sheets/2020-03-30-frequently-asked-questions-regarding-icd-10-cm-coding-covid-19
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