Coders may code a diagnosis of COVID-19 from a positive lab test, with or without a physician documenting the clinical significance of the results, according to April 17 coding guidance from the American Health Information Management Association (AHIMA) and the American Hospital Association’s (AHA) Coding Clinic.^[1] That put to rest the fear that coding based exclusively on test results jeopardized hospital claims for patients diagnosed with COVID-19, which has a new diagnosis code (U07.1).

AHIMA and Coding Clinic also recommended that hospitals “consider developing facility-specific coding guidelines to hold back coding of inpatient admissions and outpatient encounters until the test results for COVID-19 testing are available.”

Their clarification was the result of a conflict in the language of the ICD-10 Official Guidelines for Coding and Reporting.^[2] Section B4 of the coding guidelines has long said that “abnormal findings (laboratory, x-ray, pathologic, and other diagnostic results) are not coded and reported unless the provider indicates their clinical significance. If the findings are outside the normal range and the attending provider has ordered other tests to evaluate the condition or prescribed treatment, it is appropriate to ask the provider whether the abnormal finding should be added.” On April 1, CMS added to the coding guidelines for COVID-19, directing coders to “code only a confirmed diagnosis of the 2019 novel coronavirus disease (COVID-19) as documented by the provider, documentation of a positive COVID-19 test result, or a presumptive positive COVID-19 test result. For a confirmed diagnosis, assign code U07.1, COVID-19” (see Chapter 1, Sec. g).^[3]