How/When to Bill U07.1 for COVID-19
HealthTeam Advantage follows the processing guidelines from the Centers for Disease Control and Prevention (CDC).
What is diagnosis code U07.1?
Acute respiratory distress syndrome (ARDS) due to the COVID-19 virus has been identified by testing or asymptomatic patients who have tested positive for coronavirus.
When should the diagnosis U07.1 be billed?
The diagnosis code, U07.1, should only be billed when a patient has a confirmed diagnosis of coronavirus. This means the patient must have been tested prior and it came back positive for this diagnosis code to be used on the claim.
The CDC notes that this is an exception to the hospital inpatient guideline. In this case, “confirmation” does not require documentation of the type of test performed, rather a provider documentation is sufficient.
The new ICD-10 code is a primary or first-listed diagnosis code, so providers should sequence it first then use appropriate codes for associated manifestations, except in obstetric patients. CMS has also recognized the code for Medicare Severity-Diagnosis Related Group Grouper purposes effective April 1, 2020, at which time the ICD-10 the new code.
Examples of when NOT to bill the U07.1 diagnosis:
- When a patient presents with COVID-19 symptoms, but you have not yet confirmed a positive diagnosis.
- When a patient is being tested due to exposure to COVID-19.
- When a patient is being tested/screened before surgery, admission, etc.
What to bill instead of U07.1 when a positive diagnosis has not been confirmed?
The following can be found by reviewing the CDC’s ICD-10-CM Official Coding and Reporting Guidelines April 1, 2020, through September 30, 2020:
- Screening with no exposure: For asymptomatic individuals who are being screened for COVID-19 and have no known exposure to the virus, and the test results are either unknown or negative, assign code Z11.59, Encounter for screening for other viral diseases.
- Screening due to exposure: For cases where there is a concern about possible exposure to COVID-19, but this is ruled out after evaluation, assign code Z03.818, Encounter for observation for suspected exposure to other biological agents ruled out.For cases where there is an actual exposure to someone who is confirmed or suspected (not ruled out) to have COVID-19, and the exposed individual either tests negative or the test results are unknown, assign code Z20.828, Contact with and (suspected) exposure to other viral communicable diseases.
- Signs and symptoms without a definitive diagnosis of COVID-19: For patients presenting with any signs/symptoms associated with COVID-19 (such as fever, etc.) but a definitive diagnosis has not been established, assign the appropriate code(s) for each of the presenting signs and symptoms such as:
- R05 Cough
- R06.02 Shortness of breath
- R50.9 Fever, unspecified
If a patient with signs/symptoms associated with COVID-19 also has an actual or suspected contact with or exposure to someone who has COVID-19, assign Z20.828, Contact with and (suspected) exposure to other viral communicable diseases, as an additional code.
Examples of when to bill the U07.1 diagnosis:
- The patient has received a positive COVID-19 test result and is now being seen by a provider due to complications.
- The patient has recently received a positive COVID-19 test result and is admitted to the hospital due to COVID-19 complications.
- Presumptive positive COVID-19 test. A presumptive positive test result means an individual has tested positive for the virus at a local or state level, but it has not yet been confirmed by the CDC
Additional coding resources:
Centers for Medicare and Medicaid Services (CMS)
HealthTeam Advantage is always here to assist you if you have questions regarding COVID-19 billing. You can call your HealthTeam Advantage Provider Concierge at 844-806-8217 (option 2).