Pay Attention to Guidelines to Sequence COVID-19 Sequela Codes
Question: A patient presented to their pulmonologist with shortness of breath on exertion. The patient reported they’ve had symptoms for about three months following a COVID-19 infection. The pulmonologist performed spirometry with flow-volume loops, lung volumes via body plethysmography, and diffusing capacity of the lung for carbon monoxide (DLCO). After reviewing the results, the physician diagnosed the patient with persistent shortness of breath as a post-acute sequela of a SARS-CoV-2 infection. How do I report the diagnosis? Revenue Cycle Insider Subscriber Answer: You’ll report two ICD-10-CM codes for the documented diagnosis. Assign U09.9 (Post COVID-19 condition, unspecified) to report the post-acute sequela of COVID-19. However, you’ll notice a Code first note listed under the code, which instructs you to code the condition that is occurring as a result of the previous COVID-19 infection. In your case, you’ll need a code to represent the shortness of breath. Assign R06.02 (Shortness of breath) as the primary diagnosis code to report the patient’s dyspnea. Your secondary diagnosis code will be U09.9. According to the ICD-10-CM Official Guidelines, Section I.C.1.g.1.m, “For sequela of COVID-19, or associated symptoms or conditions that develop following a previous COVID-19 infection, assign a code(s) for the specific symptom(s) or condition(s) related to the previous COVID-19 infection, if known, and code U09.9.” Mike Shaughnessy, BA, CPC, Production Editor, AAPC
