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Clinical Documentation Improvement Tips: COVID-19DefinitionsCOVID-19. Defined by World Health Organization as “A respiratory tract infection caused by a newly emergent coronavirus, SARS-CoV-2, that was first recognized in Wuhan, China in December 2019. Symptoms. Severe symptoms include Acute Respiratory Distress Syndrome (ARDS), sepsis, septic shock, multiorgan failure including AKI and Cardiac Injury. Symptoms in immunocompromised patients may be atypical. Source: WHO 2020, Mar 13 TreatmentScreening for symptoms, travel to identified outbreak areas, contact with known infected personsIsolation – airborne precautionsTesting – currently may be tested with a nasal swab at OSH or KU laboratory Medications – Hydroxychloroquine (Plaquenil) and azrithromycin (Zithromax), or other trial medicationsAdditional treatment aimed at manifestations of the illness, including sepsis, acute respiratory failure, circulatory disfunction, cardiac dysfunction, renal failureSpecial Casesn/a currently Documentation-477520219161Link manifestations of the disease to the infection (eg. Pneumonia due to COVID-19) CodingCodes in the ICD-10 Chapter 22 “Codes for Special Purposes” and “Provisional assignment of new diseases of uncertainly etiology or emergency use” will be used for COVID-19 infections beginning April 1, 2019 (discharge date). -453807164017Patient Discharged on or after 4/1/2020U07.1 COVID-19 infection*This code is the principal diagnosis UNLESS the patient is SEPTIC, use SEPSIS as PDx. Secondary codes needed for pneumonia or other manifestations of the disease (including coronavirus as cause of disease classified elsewhere (e.g.GI manifestations (B97.2) and SARS (J12.81))Excludes1: Coronavirus infection of unspecified site (B34.2) – to be used rarelyRuled out cases are not to be coded. No z-codes are neededReferencesWorld Health Organization (2020, Mar 13) “Clinical management of severe acute respiratory infection when COVID-19 disease is suspected. Interim Guidance.” Accessed 3/30/2020 from who.int CDC. Coronavirus (COVID-19) website accessed 3/30/2020 Butler, R. (2020, Mar 18). “CDC announces April 1 implementation of ICD-10-CM COVID-19 code). Email distribution list from 3M 21149012872432Discharges on after 4/1/20020000Discharges on after 4/1/202075336427853Discharges on or before 3/31/20020000Discharges on or before 3/31/20 ................
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