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The dilemma of coding COVID-19 is revealed.

One of the things that delights me about ICD-10-CM is that I find new codes (codes new to me, that is) almost daily. And I also think ICD-10-CM is pretty logical; the answers to conundrums are there, if you have faith that almost every scenario can be described in codes.

I monitor some of the American Health Information Management Association (AHIMA) forums, and the day before Christmas, a question was posed as to how to code drive-up COVID-19 testing. Let me preface this with two disclaimers: first, I am not a coder; I just play one on Talk Ten Tuesdays. And second, I have no idea whether payers are going to pay for the diagnoses that make sense to me.

A poster named Jennifer suggested the possibility of using Z02.0 and Z02.1 on the claims, so I looked them up. I squealed with delight when I read the descriptions. Z02.0 is Encounter for examination for admission to educational institution, and Z02.1 is Encounter for pre-employment examination (although indexing seems to land “employment examination” here, too). In this same set of encounters for administrative examinations, I also found Z02.2, Encounter for examination to residential institution. Intuitively, these fit with COVID-19 testing for permission to return back to school or work or a nursing home. Indeed, Z02.5, Encounter for examination for participation in sport, probably also pertains to those naughty athletes who slip out of their professional sports bubbles and end up with potential exposure.

The forum question also noted that Z11.59, the generic screening code, was causing a battle, and Jennifer didn’t think this should be listed on these claims because, “you know, we are in a pandemic.” Let’s tackle that one first. She is completely correct – there is no screening in pandemics. I am going to refer you all to the updated Official Coding Guidelines, page 31, where the revision for 2021 regarding screening during the pandemic reads, “do not assign code Z11.52, Encounter for screening for COVID-19,” in bright red letters.

The instructions for routine and administrative examinations also have a few caveats, which introduce some uncertainty. The codes are “not to be used if the examination is for diagnosis of a suspected condition, or for treatment purposes.” I interpret this to mean that if the patient were to have a genuine concern that they have (in this case) COVID-19, and the exam and testing were aimed at ruling disease in/out (as opposed to being performed for administrative purposes), you wouldn’t use a Z02.- code.

The second ambiguous sentence is “pre-existing and chronic conditions and history codes may also be included as additional codes, as long as the examination is for administrative purposes and not focused on any particular condition.” At first I was wondering if this really did exclude COVID-19 testing from being done under the Z02.- umbrella – there is a focus on a particular condition. Then I considered Z02.4, Encounter for examination for driving license. You do not undergo a comprehensive physical examination for this; you have your vision tested, and perhaps reflexes and judgment. It is my opinion that the heart of the matter is what the purpose of the specific or general assessment is (can you see well enough to drive? Do you have scoliosis or a heart arrhythmia, which would preclude participating in sports? Are you infected with a communicable disease, which would make you a risk to colleagues and customers?) – not what or how many body systems are being examined, evaluated, assessed, or tested.

Accordingly, Z02.- codes intuitively make sense to me for situations in which an entity other than the patient or the medical provider (in other words, an administrative entity) is requesting or demanding a test (like a judge ordering a paternity test in Z02.81). Situations like your job or college requiring a negative COVID-19 test to permit you to work or to return to campus after spring break would fall into that administrative category.

If a patient presents to a drive-up testing facility asking for a COVID-19 test because their boss or school demands one, a Z02.- code may be appropriate. It appears that you are permitted to use the exposure code in conjunction.

If the drive-up individual is asking for a COVID-19 test because they are concerned they may have had an exposure and they want to know if they are infected, then Z20.822, Contact with and (suspected) exposure to COVID-19, would be the correct ICD-10-CM code. If the person has symptoms prompting the testing, the symptoms would be the diagnosis codes, and Z20.822 could, again, be a secondary diagnosis.

What happens if one of these administrative tests is done on an inpatient basis, e.g., the skilled nursing facility (SNF) has to have a negative COVID-19 test to permit a return to the patient’s bed? Since Z02.- is a mandatory principal or first-listed diagnosis, it is obviously inappropriate to code.

How about a follow-up after a bout of COVID-19? We are instructed to use Z09, Encounter for follow-up examination after completed treatment for conditions other than malignant neoplasm, plus Z86.16, Personal history of COVID-19. Can you use Z02.- as well? If I read the guidelines correctly, you may, but the Z02.- would have to be first-listed.

Finally, if any of these tests turn out to be positive, unless a provider documents otherwise (e.g., “I believe the positive test represents viral remnants and do not believe the patient currently has COVID-19”), the U07.1 code for COVID-19 would depose Z20.822.

The last consideration that I alluded to in the introduction is, “will payers pay for Z02.-?” I have a concern that they would not, but I have to confess that I am a theoretician. I don’t submit claims, and likewise, I am not privy to denials, unless one of you or a client shares that with me. I also do not know practically, if you used both Z02.- and Z20.822, whether the payer would pick up the Z20.822 and reimburse the claim based on that being a legitimate, medically necessary diagnosis.

Crowd-sourcing time: what do you think? Have you used this set of codes? Did the payers pay? Let us know! Email us at editor@icd10monitor.com

None of you have let me know yet whether the insurers are paying for Z02.- codes, but I have been informed that the American Hospital Association (AHA) Coding Clinic’s advice for return to work is to use Z02.89, Encounter for other administrative examinations. Z02.0, Encounter for examination for admission to educational institution, is confirmed as being the correct code to use for return-to-school COVID-19 testing. If the patient has had exposure and school/work are mandating testing, you use the same codes, along with Z20.822, Contact with and (suspected) exposure to COVID-19.

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Erica E. Remer, MD, CCDS

Erica Remer, MD, FACEP, CCDS, has a unique perspective as a practicing emergency physician for 25 years, with extensive coding, CDI, and ICD-10 expertise. As physician advisor for University Hospitals Health System in Cleveland, Ohio for four years, she trained 2,700 providers in ICD-10, closed hundreds of queries, fought numerous DRG clinical determination and medical necessity denials, and educated CDI specialists and healthcare providers with engaging, case-based presentations. She transitioned to independent consulting in July 2016. Dr. Remer is a member of the ICD10monitor editorial board and is the co-host on the popular Talk Ten Tuesdays weekly, live Internet radio broadcasts.

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