By: Cynthia Tang, RHIA, CCS, Pinson&Tang

In another unprecedented mid-year ICD-10 classification update, new COVID-19 related codes have been created effective January 1, 2021. The new COVID-19-related ICD-10-CM codes are:

J12.82 Pneumonia due to coronavirus disease 2019
M31.81 Multisystem inflammatory syndrome
M35.89 Other specified systemic involvement of connective tissue
Z11.52 Encounter for screening for COVID-19
Z20.822 Contact with and (suspected) exposure to COVID-19
Z86.16 Personal history of COVID-19

There are also 21 new procedure codes to describe the introduction or infusion of therapeutics, including monoclonal antibodies and vaccines for COVID-19 treatment—although these codes will not affect DRG assignment. Medicare will pay for the COVID-19 vaccines and their administration separately from the DRG rate. The CPT codes should be reported when the vaccine is administered while a hospital inpatient.

Medicare Requirement for 20% Payment Increase Requires Positive Test Result

Effective with admissions occurring on or after September 1, 2020, claims eligible for the 20 percent increase in the MS-DRG weighting factor will also be required to have a positive COVID-19 laboratory test documented in the patient’s medical record. The viral test can either be performed during the hospital admission or within 14 days prior to the hospital admission.

Although the official coding guidelines state that the provider’s documentation that the individual has COVID-19 is sufficient to code U07.1, claims eligible for the additional 20% now require a positive test result in the medical record which wasn’t required prior to September 1.

CMS may conduct post-payment audits to confirm the presence of a positive COVID-19 laboratory test and recoup the 20 percent increase if no such test is contained in the medical record.  Although hospitals should continue to code U07.1 when the diagnosis meets the official coding guidelines definition of COVID-19, if the record does not have evidence of a positive test result hospitals can decline the additional payment at the time of claim submission to avoid the repayment.

For more information, see MLN Matters SE20015.

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