Documenting COVID-19


Coronaviruses are a large family of viruses that cause illness ranging from the common cold to more severe diseases. SARS-CoV-2—COVID-19—is a new strain that was discovered in 2019 and is behind the current global pandemic. As of May 31, there are over 1.7 million confirmed cases and over 100,000 deaths in the US. Older adults and people who have severe underlying medical conditions, such as heart or lung disease or diabetes, seem to be at higher risk for developing more serious complications from COVID-19. People who may have COVID-19 might exhibit these signs and symptoms:

  • Persistent, dry cough
  • Shortness of breath or difficulty breathing
  • Fever
  • Chills
  • Muscle pain
  • Sore throat
  • New loss of taste and/or smell

Clinical documentation integrity (CDI) professionals need to educate providers on the importance of accurately documenting the presentation of COVID-19 patients. Capturing acuity, severity, and risk with secondary diagnoses is essential in educating CDI teams to accurately capture diagnoses that correctly reflect a patient’s severity of illness based on the ICD-10-CM guidelines for COVID-19. Furthermore, capturing this data will be helpful in supporting epidemiology with chronic conditions.

Data integrity is needed to support greater clinical understanding of COVID-19 and all its manifestations. Without the full list of acute manifestations and sequelae, as well as chronic conditions, it will be challenging to determine the full extent of this disease and who should need higher levels of care and screening. Furthermore, vigorous collection of data helps in the process of providing information for future pandemic preparation.

Providers need to fully document the acuity of the COVID-19 population because patient care needs are best supported by hard data. Furthermore, providers need to document all aspects of the infection with appropriate linkages of causes and effects and explicit documentation regarding the etiology of the infection.

The ICD-10-CM code U07.1 is effective for discharges on or after April 1, 2020. CDI professionals need to use additional codes to identify pneumonia or other manifestations. The Excludes1 Note includes:

  • Coronavirus infection, unspecified (B34.2)
  • Coronavirus as the cause of diseases classified elsewhere (B97.2-)
  • Pneumonia due to SARS-associated coronavirus (J12.81)

Diagnoses associated with COVID-19 infections include:

  • Pneumonia
  • Acute respiratory failure
  • Acute respiratory distress syndrome (ARDS)
  • Acute exacerbation of chronic obstructive pulmonary disease (COPD)
  • Viral sepsis with organ dysfunction ranging from encephalopathy, acute kidney injury, and shock
  • Leukopenia
  • Procedure for intubation for mechanical ventilation
  • Cardiac injury to infarction (often non-ST elevation myocardial infarction [NSTEMI] Type 2)
  • Stroke

People with COVID-19 can experience bronchitis and upper respiratory tract infections. Bronchitis is an inflammation of the bronchial airways due to infectious or non-infectious causes. Clarification of the acuity is needed any time we see that the physician hasn’t been mentioning if the condition is acute or subacute.

ARDS is caused by diffuse damage to the alveolar-capillary interface (diffuse alveolar damage). Furthermore, leakage of protein-rich fluid leads to edema that combines with necrotic epithelial cells to form hyaline membranes lining alveoli. The clinical features include hypoxemia and cyanosis with respiratory distress due to thickened diffusion barrier and collapse of air sacs (increased surface tension) and “white-out” on chest X-ray

ARDS can occur secondary to severe COVID-19 and other disease processes as well, including sepsis, infection, shock, trauma, aspiration, pancreatitis, disseminated intravascular coagulation, and hypersensitivity reactions. Activation of neutrophils induces protease- and free radical–mediated damage of type 1 and type 2 pneumocytes. Treatment includes addressing the underlying cause and ventilation with positive end-expiratory pressure (PEEP). CDI professionals need to look for respiratory failure clinical indicators such as shortness of breath, tachypnea, labored breathing, diaphoretic, and paleness. This condition is developed more commonly in people who have the following risk factors: immunocompromised individuals, COPD, chest trauma, and fluid overload. CDI professionals need to review the medical record thoroughly and ensure that respiratory failure clinical indicators are clearly noted to validate the diagnosis, otherwise a clinical validation query might be necessary. They need to make sure the query is not leading in nature.

CDI professionals need to ensure documentation of type and acuity are present in the record. Furthermore, acute respiratory failure cannot be coded with adult respiratory distress syndrome. Recovery may be complicated by interstitial fibrosis, damage, and loss of type 2 pneumocytes that can lead to scarring and fibrosis.

Elevated Troponin is something that is common among critically ill patients with COVID-19 and generally does not represent a type 1 (plaque rupture) myocardial infarction. Most commonly, it represents a type 2 myocardial infarction, which shows evidence of an imbalance between myocardial oxygen supply and demand unrelated to coronary thrombosis. Viral cardiomyopathy is a progression of viral myocarditis, which involves the thickening of the myocardium and dilation of the ventricles. Diagnosis evidence can be made via echo, cardiac MRI, and myocardial biopsy. Furthermore, viral cardiomyopathy can further degenerate into acute (or chronic) heart failure and dilated ventricles can result in low cardiac output (ejection fraction). Sustained low blood pressure with tissue hypoperfusion despite adequate left ventricular filling pressure can lead to cardiogenic shock. Cardiogenic shock treatment includes fluid bolus, transfusions, vasopressors (such as Neo-Synephrine) and inotropes (such as dobutamine), IABP, and ECMO.

COVID-19 can only be coded with confirmation of the virus by the provider, which includes presumptive positive test results. For a confirmed diagnosis, CDI professionals need to assign code U07.1, COVID-19. Presumptive positive COVID-19 test results mean an individual has tested positive for the virus at a local or state level, but it has not yet been confirmed by the Centers for Disease Control and Prevention and should be coded as positive. According to the guidelines, “If the provider documents ‘suspected,’ ‘possible,’ ‘probable,’ or ‘inconclusive’ COVID-19, do not assign code U07.1. Assign a code(s) explaining the reason for encounter (such as fever) or Z20.828, Contact with and (suspected) exposure to other viral communicable diseases.


AHIMA. AHIMA Inpatient Query Toolkit. 2017.

Benezit, Francois et al. “Utility of hyposmia and hypogeusia for the diagnosis of COVID-19.” The Lancet. April 15, 2020.

AHIMA. “CDC Publishes Final COVID-19 ICD-10-CM Guidelines.” Journal of AHIMA. March 31, 2020.  


Alba Kuqi ([email protected]) is the CDI supervisor at Prime Healthcare. She is an ACDIS Leadership Council member, PHIMA member, and AHIMA Foundation Research Network Volunteer.

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