CMS Responds to Follow-up Questions Related to New COVID-19 ICD-10 Codes & Coding

Medicare
New ICD-10 codes were recently introduced off-cycle for COVID-19 effective January 1, 2021, and the Centers for Medicare and Medicaid Services (CMS) posted updated coding guidance when there was a COVID-related condition. Additionally, CMS also updated the PDPM Mappings file to incorporate the newly introduced codes. Some of the new COVID-19 related codes map to RTP and cannot be used as primary reason for SNF stay in item I0020B of the MDS.   

Several members have raised concerns about coding on a PPS 5-day or IPA assessment if the patient has previously tested positive for COVID and was symptomatic, but since then, have tested negative but needs skilled care due to a COVID-related condition (i.e. pneumonia). AHCA/NCAL asked CMS to clarify and was provided the below response. AHCA recommends that you forward this information to MDS assessment and billing staff.   
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When we updated the ICD-10 code mappings for the SNF PDPM clinical categories effective 1/1/2021, we added four new codes related to a diagnosis of COVID-19 to the Return to Provider (RTP) category. Specifically, code J1282, Pneumonia due to coronavirus disease 2019 ; code Z1152, Encounter for screening for COVID-19 ; code Z20822, Contact with and (suspected) exposure to COVID-19 ; and code Z8616, Personal history of COVID-19, were added to the code mappings. 

These RTP codes cannot be used as a primary diagnosis code for a Part A SNF patient. However, in some cases, a patient may receive a diagnosis of pneumonia due to COVID-19 (J1282), which becomes the primary reason for their SNF stay, even after the patient subsequently tests negative for COVID-19. In these cases, as long as the patient still has COVID-associated pneumonia, code U07.1 should continue to be assigned, and U07.1 would be sequenced first. Code J1282 cannot be sequenced first. 
 
This is in accordance with the “code first” guidance in the ICD-10-CM Official Guidelines for Coding and Reporting (available online at https://www.cms.gov/files/document/2021-coding-guidelines-updated-12162020.pdf​ ) : 

1. (i) Pneumonia For a patient with pneumonia confirmed as due to COVID-19, assign codes U07.1, COVID-19, and J12.82, Pneumonia due to coronavirus disease 2019 
 
Regardless of whether the patient’s most recent COVID test is positive or negative, code U07.1 should continue to be assigned as long as the patient has a current, acute manifestation of COVID, such as pneumonia. 

I hope this addresses your questions regarding the pneumonia code J1282 and coding for pneumonia diagnoses that are manifestations of a COVID-19 diagnosis that has become negative.       

We have requested that CMS add this clarification to its published COVID-19 guidance, which may take some time due to clearance processes. Questions can be sent to COVID19@ahca.org.