While it is not in the news on a daily basis any longer, COVID has not gone away. Since the start of the pandemic, we have seen waves of infection and different variants.
There may be a lot of things about the COVID pandemic we would like to forget, but our coding guidelines shouldn’t be one of them. Today we will revisit some COVID coding guidance.
An article in Prevention last month identified the XEC variant as the latest one spreading through the United States. XEC has been detected in the U.S. and Europe after first being identified in Germany in June 2024.
This variant is thought to be a hybrid of the Omicron subvariants KS.1.1 and KP.3.3. KP.3 is the family of FLiRT variants, and K.P.3.1.1 is still the dominant strain in the U.S. These variants were seen during our summer wave of COVID cases.
According to Yale Medicine, as of early this month the XEC variant accounted for an estimated 28 percent of all COVID cases in the US. The K.P.3.1.1. variant accounted for an estimated 52 percent of all U.S. COVID cases.
Let’s look back at COVID coding. We are surely all familiar with the U07.1 code for COVID-19. As you probably remember, this code became effective April 1, 2020, as part of that unprecedented off-cycle update to the code set, which was necessary to respond to the pandemic.
U07.1 is considered a Major Complication or Comorbidity (MCC) for MS-DRG grouping purposes. There are two additional code notes on U07.1. One guides the coder to use an additional code to identify pneumonia or other manifestations – and it lists
“pneumonia due to COVID-19.” The other instructs the coder to use an additional code, if applicable, for associated conditions such as COVID-19-associated coagulopathy, disseminated intravascular coagulation, hypercoagulable states, and thrombophilia.
According to the Official Guidelines for Coding and Reporting, these additional code notes indicate the proper sequencing order of the codes: etiology followed by manifestation. In the tabular index there will be a “code first” note on those manifestation codes.
Pneumonia due to COVID-19 is assigned to J12.82, Pneumonia due to coronavirus disease 2019. This manifestation code will be sequenced after the U07.1 COVID etiology code. J12.82 took effect as of Jan. 1, 2021 in another off-cycle update in response to the pandemic. Other COVID-related codes were also included in that update, including Z86.16, Personal history of COVID-19.
Another important guideline to remember is that we only code confirmed COVID-19 cases. Official Guidelines let us know that this is an exception to the hospital inpatient guideline. It further instructs that a positive test result is not required here. The provider’s documentation that the patient has COVID-19 is enough. If a provider documents a COVID-19 diagnosis as “suspected,” “possible,” “probable,” or “inconclusive” we would code any signs and symptoms reported and not U07.1.
While these guidelines and codes are not new, I think it is a worthwhile exercise to reintroduce ourselves with them. Even though we have models to predict when infection waves may occur, no one knows for sure how the fall/winter season will play out in terms of COVID infections. In the weeks ahead we will be looking at long COVID and coding for post-acute conditions.
Here’s hoping you and your family have healthy, happy months ahead!
The Centers for Medicare & Medicaid Services (CMS) released in its 2025 Outpatient Prospective Payment System (OPPS) Final Rule a new Conditions of Participation (CoPs)
Coding in the post-acute care world has taken on a new significance in the past five years. For those of us who are coders, this
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