What We Currently Know about the Sequela Effects of COVID-19

We are learning more every day about the sequela conditions that might arise as a result of COVID-19. The early studies have found decreased lung function that might not be reversible, as well as potentially permanent damage to the heart, kidneys, and liver, along with GI conditions. Scientists and clinicians typically have focused on the acute phase of COVID-19, but is has become increasingly clear that many patients who have recovered may need continuous monitoring for long-term effects.

In a research letter published online July 9 in the Journal of the American Medical Association (JAMA), Angelo Carfi, MD and colleagues from the Gemelli COVID-19 post-acute care study group in Rome, Italy reported that “87.4 percent of 143 previously hospitalized patients had at least one persistent symptom two months or longer after the initial onset, and at more than a month after discharge.”

In the United States, many practitioners are now seeing patients who were first diagnosed with COVID-19 in March or April still having symptoms. Some patients experience ongoing shortness of breath, coughing, fatigue, persistent chest pain on exertion, blood clotting (DVTs), poor concentration, cardiovascular complications, gastrointestinal distress, reduced muscle strength and impaired grasping power, dizziness, neurological complications, and/or conditions such as seizures or strokes, to name a few. Patients have even been known to develop post-traumatic stress disorder or depression. Recovery can be slow, incomplete, and costly, with a huge impact on quality of life.

We may see more sequela conditions emerge as more people recover. Some clinicians are seeing permanent lung scarring or damage on imaging. Practitioners will probably continue to treat many more patients with specific conditions and/or signs/symptoms post-COVID-19. With so many new cases of COVID-19 emerging on a daily basis, this is only the beginning.

What is a sequela? A sequela is a residual or late effect (condition-produced) after the acute phase of an illness or injury has terminated. There is no time limit on when a sequela code can be used. The residual effect may be apparent early, such as in cerebral infarction, or it may occur months or years later, such as that due to a previous illness or injury. How do we code sequelae of COVID-19?

For coding all late effects or sequelae of COVID-19, confirmed by COVID testing or documentation in the practitioner’s record indicating the patient had COVID-19:

• Code first all the condition(s) being treated related to COVID (e.g., shortness of breath, DVT, etc.)
• Use the additional code B94.8-Sequelae to identify the late effect.

Example: A patient is seen by his internal medicine physician in July after suffering from COVID-19 in April. The patient complains of continuous shortness of breath and fatigue, and even though the symptoms are not as severe as when he had COVID, the patient is still in discomfort.

Coding: Shortness of Breath R06.02

Fatigue R53.83-other fatigue

Sequela: B94.8

When not certain if the condition treated during the encounter is a sequela of COVID-19, but the patient had a confirmed diagnosis of COVID-19 either by testing or confirmation in the practitioner’s documentation:

• Code first the condition you are treating
• Use Z86.19-Personal history of other infectious and parasitic diseases as an additional diagnosis

Example: A patient is seen by his internal medicine physician in July in follow-up for her hypertension. Her blood pressure is well-controlled by medication. The patient had COVID-19 in March and is not experiencing any late effects. Her last chest X-ray was normal. The patient will return in six months for follow-up on her hypertension.

Coding:  Hypertension-I10

Personal history of other infectious and parasitic diseases-Z86.19

There is no specific timeframe for when a personal history code is assigned. If the practitioner documents that the patient no longer has COVID-19, the personal history code Z86.19 can be assigned as an additional diagnosis.

One more example: A patient previously had COVID-19 and is seen in follow-up after completed treatment, and the patient does not have a related sequela condition and/or symptoms. In this scenario you would code the following:

• Z09-encounter for follow-up examination after completed treatment for other conditions other than malignant neoplasm
• Z86.19- Personal history of other infectious and parasitic diseases

Documentation Tips for Sequela of COVID-19
It is important that when coding sequela of COVID-19, the practitioner documents that the condition is a late effect of COVID. If the practitioner’s documentation indicates multisystem inflammatory syndrome, the practitioner needs to document the affected organs in order to code correctly. If the patient is experiencing signs or symptoms that are sequelae of COVID-19, code all signs and/or symptoms that are relevant. Be specific, because documentation must include the relationship with COVID-19 in order to code the condition as a sequela. And lastly, query the practitioner if the documentation is not clear. Physicians should also document any patient counseling related to prevention measures to reduce the spread of COVID-19.

Programming Note: Deborah Grider will co-host Talk Ten Tuesdays this morning at 10 a.m. EST, sitting in for Dr. Erica Remer. Register to listen.