How to Code for COVID-19 and the necessity of legal disclaimers (Updated Article)

- Anton van Schalkwyk (Medical Coding Specialist, SAMA)

(Special mention should be made of Dr Bernard van der Westhuizen, whose measures that were taken to protect his practice inspired a portion of this article).

Also a special thank you to SAMA’s legal division for assisting to protect our practices on such short notice by putting together the disclaimers that will be available shortly.

With COVID-19 infecting more and more people in South Africa, it is crucial that doctors in private practice arm themselves with the necessary knowledge in order to be able to claim for medical services rendered to patients from the various medical schemes.

The question of course is: How do we code for it in order to ensure that the statistical data within our healthcare system, as well as that being recorded internationally is clear. Additionally, how do we code for the services rendered, especially Telehealth services. It is also important that doctors do everything possible in order to protect themselves from liability claims because of the limitations related to Telemedicine services rendered. Additional protective measures should also be extended to face-to-face contacts for the duration of the pandemic, related to possible infections that could result from physical contact with them and their consulting rooms.

1. ICD-10 Coding

On 18 March 2020 the World Health Organisation has updated the ICD-10 coding structure in order to allow for more diverse coding options. When allowing for maintaining the standard of the South African Master Industry Table (MIT), the ICD-10 coding options would be as follows:

ICD-10

New WHO description

South African Description to use

WHO Interpretation

U07.1

COVID-19, Virus Identified

Emergency use of U07.1

- Use this code when COVID-19 has been confirmed by laboratory testing irrespective of severity of clinical signs or symptoms
- Use additional code, if desired, to identify pneumonia or other manifestations.

U07.2

COVID-19, virus not identified

Emergency use of U07.2

- Use this code when COVID-19 is diagnosed clinically or epidemiologically but laboratory testing is inconclusive or not available.
- COVID-19 NOS
- Use additional code, if desired, to identify pneumonia or other manifestations

Other ICD-10 Codes to take into consideration for COVID-19 as prescribed by the WHO:

ICD-10

WHO description

South African MIT Description to use

WHO interpretation for COVID-19 testing

Z11.5

Special screening examination for other viral diseases.

Special screening examination for other viral diseases.

Z03.8

Observation for other suspected diseases and conditions

Observation for other suspected diseases and conditions

suspected but ruled out by negative laboratory results

It is important to note that without formal confirmation via laboratory testing, ICD-10 U07.1 should not be used under any circumstances. For screening of COVID-19, Z11.5 should be used.

The Private Healthcare Information Standards Committee (PHISC) has put the following examples forward when confronted with COVID-19 related coding:

Example 1: Patient admitted with a fever, coughing and shortness of breath. Pathology confirms the cause is Coronavirus disease

Primary ICD-10 Code: U07.1 Emergency use of U07.1

Example 2: A patient diagnosed with pathology confirmed COVID-19 is presenting with acute respiratory failure.

Primary ICD-10: J96.09 Acute respiratory failure, Type unspecified.

Secondary ICD-10: U07.1 Emergency use of U07.1.

Until such time as pathology confirms the cause of the disease, Z11.5 (Special screening for other viral diseases) should be used instead of U07.1.

Example 3: Patient admitted with shortness of breath and a fever. Coronavirus disease is suspected, bloods have been sent to the laboratory for testing.
Primary ICD-10: R06.0 Dyspnoea
Secondary ICD-10: R50.9 Fever, unspecified
Secondary ICD-10: Z11.5 Special screening examination for other viral diseases

After confirmation by pathology that it is indeed an infection caused by COVID-19, the Z11.5 may be replaced with U07.1 (Emergency use of U07.1).

Example 4 (Not put forward by PHISC): A further example that could be provided would be the following:

Patient comes in with symptoms that are in line with COVID-19. The patient’s history includes direct contact with someone that has already been positively diagnosed. Symptoms include acute respiratory failure and needs to be ventilated. The patient also presents with a high fever. Laboratory results are not in yet, but the patient’s history and symptoms indicates a very high probability that t0he patient has been infected with the COVID-19 virus:

Primary ICD-10: J96.09 Acute respiratory failure, Type unspecified

Secondary ICD-10: R50.9 Fever, unspecified

Secondary ICD-10: U07.2 Emergency use of U07.2

After pathology results has confirmed positive identification of COVID-19, the ICD-10 U07.2 must be changed to U07.1.

Example 5 (Not put forward by PHISC): Patient came into contact with someone that was infected with COVID-19 and is showing some mild symptoms that might indicate COVID-19. The doctor refers the patient for testing to rule out COVID-19. The test came back negative.

Primary ICD-10 code: Z11.5 Special screening examination for other viral diseases

After the results became known, change the ICD-10 code to:

Primary ICD-10 code: Z03.8 Observation for other suspected diseases and conditions.

It would be necessary to add ICD-10 codes that are consistent with a more apt diagnosis or in line with the patient’s symptoms.

2. Telemedicine during the COVID-19 outbreak

Very few aspiring medical students ever think that they will put their lives on the line to fulfil their life calling to serve their patients as medical doctors. Yet, with the COVID-19 pandemic such a possibility has become a daunting reality for all healthcare professionals around the world.

The Health Professionals Counsel of South Africa (HPCSA) has made their latest guidelines available for telemedicine in light of the pandemic and its presence in South Africa. The two most important points to take note of are:

1. It is only valid for these extraordinary circumstances until notice will be provided that they are going to revert back to the previous rulings.
2. Telemedicine is only to be provided for existing patients and may not be provided for unknown patients. The only exceptions would be Telepsychology and Telepsychiatry

“Telemedicine” is also being replaced by a more global term, Telehealth, which would include Telemedicine, Telepsychology, Telepsychiatry, Telerehabilitation, etc. It would involve remote consultation with patients using telephonic or virtual platforms of consultation (e.g. skype).

It is also notable that the HPCSA has made it clear that should a remote consultation not be in the best interest of the patient, it is important for such a patient to be encouraged to come in for a face-to-face consultation. Patients should still be afforded the opportunity to have face-to-face visits with their doctors.

Refer to this link for the full release by the HPCSA: https://www.hpcsa-blogs.co.za/covid-19-hpcsa-guidelines-for-healthcare-practitioners/

3. Medical Doctor coding for Telemedicine:

It is important to know that the normal items 0190-0193 are not suitable for remote consultations of any kind – whether through telephone conversations or video platforms. There are several reasons for this:

1. Items 0190-0193 clearly states that it is reserved ONLY for face-to-face visits or consultations.

2. A remote consultation may never be equated to a visit in the rooms where the doctor takes the time to do a physical examination of the patient, which is what items 0190-0193 were designed for.

3. It is important to note that, through their latest communication regarding Telehealth, the HPCSA did not state in any way that remote consultations are to be coded as if it is a visit in the rooms, but merely that “Practitioners may charge a fee for services rendered through a telehealth platform.” Their latest position is merely an acknowledgement of the unusual circumstances that would make Telehealth as preferred method of consultation permissible during the time of national crisis.

For remote telemedicine doctors may code Item 0130:

0130 Telephone Consultations (all hours)

Should a prescription be needed to be written and sent to the patient, the practitioner may add Item 0132 to Item 0130. Prescriptions may be emailed or faxed to the patient or pharmacy of their choice. It is important to add the appropriate ICD-10 code(s) to support the claim.

0132 Consulting service, e.g. writing of repeat scripts or requesting routine pre-authorisation without the physical presence of the patient (needs not be face-to-face contact) (“Consultation” via SMS or electronic media included)
• Patients are personally liable for these accounts if not covered by their medical scheme benefits

For existing patients with chronic diseases who are under the care of the doctor it may be beneficial to consider writing a repeat script for a shorter period than the usual six months, in order to facilitate a face-to-face visit at an earlier date for more effective monitoring of their condition. In this regard Medical Schemes should realise that there is going to be a spike in the utilisation of item 0132 in many cases in order to ensure the continued effective treatment of these patients.

It is highly recommended that, should a patient be new to the practice, they should be counselled and referred to their nearest COVID-19 centre. It is therefore important that practitioners familiarise themselves with the availability and locations of such centres in their towns and cities.

It is also advisable that a motivation should be provided with claims to the funders when it is a new patient to explain that the intention of the consultation was to counsel the patient with information only and refer them to the appropriate centres and clinics. This is in order for medical practitioners to be able to claim for their time spent in consultation and ensure that they are compliant with the guidelines of the HPCSA. It would also not be advisable to fill out a prescription to a patient not previously known to the practice and it would therefore be ill advised to code for Item 0132.

Item 0130 would be for limited use and no prolonged telehealth discussions are provided for. Face-to-face encounters should still be viewed as the norm for prolonged consultations. Medical practitioners should always be cognisant of the fact that the HPCSA’s ethical rules are still governing the profession and that it must at all times be adhered to.

4. Medical Schemes and Telehealth.

Some of the schemes have developed in-house platforms and codes regarding telehealth. Please check with specific medical schemes if they made provision for a unique code(s) and platforms for Telehealth. For example Discovery Health informed their members that a doctor can claim according to the HealthID and are encouraging doctors to register on HealthID and DrConnect. SAMA has received information regarding such in-house platforms and coding from both Discovery Health and Medscheme. These communications are being attached to the bottom of this article for your convenience.

5. Testing for Covid-19:

5.1 When medical practitioners take swabs for testing:

When a medical practitioner performs the swab for testing, the taking of the swab forms part of the consultation or visit item code (item 0190-0193) where the patient is physically consulted by the doctor and cannot be coded separately. It is important that practitioners familiarise themselves with the National Institute for Communicable Diseases’ (NICD) protocols in order to protect themselves and their patients and how to comply with the directives from the Department of Health. All the necessary information may be obtained from the NICD website: https://www.nicd.ac.za/diseases-a-z-index/covid-19/covid-19-guidelines/.

5.2 Pathology Laboratory coding for COVID-19 testing

Each medical scheme currently has its own in-house code that they accept for pathology laboratories. The National Pathology Group has confirmed that they currently use three codes to claim from the various medical schemes. Discovery Health for instance has developed C019, while codes 3979 and 9995 are also being accepted by various medical schemes. Please note that these codes do not form part of the SAMA Medical Doctors’ Coding Manual structure and independent laboratories should confirm with the various schemes which codes would be accepted.

6. Telepsychiatry

It is notable that the HPCSA made an exception to the ban on first time patients and Telehealth when it comes to psychology and psychiatry.

It is important that psychiatrists contact the South African Society of Psychiatrists (SASOP) in order to obtain the full coding guidelines regarding Telepsychiatry. It is also worth noting that they developed a consent form for patients to sign.

7. The Counsel for Medical Schemes (CMS) on COVID-19

On 26 March 2020 the CMS has published Circular 25 of 2020: COVID-19 lockdown measures.

Two important points are being made in this document with regards to claims to medical schemes:

1. COVID-19 is a Prescribed Minimum Benefit (PMB) condition
All cases of COVID 19 are regarded as Prescribed Minimum Benefits (PMB) condition, and should be funded in full in line with the current NICD guidelines as published.
In line with clinical protocols and benefit guidelines, this should cover:
· All consultations;
· All clinically appropriate diagnostic tests including Viral PCR;
· All clinically appropriate medication; and
· Costs of hospitalisation including all complications and rehabilitation.
In accordance with the Medical Schemes Act of 1998, the use of designated service providers, clinical protocols and formularies should apply. This will apply for as long as the epidemic persists.
 2. Telemedicine
The CMS encourages the usage and appropriate funding of Telehealth consultations in accordance with updated notice on the Health Professions Council of South Africa (HPCSA) regulatory guidelines. The full guideline may be downloaded here: https://www.medicalschemes.com/files/Circulars/Circular25Of2020.pdf

8. The necessity of a disclaimer: Informing patients of the unusual circumstances and recordkeeping thereof.

Because of the additional risk in evaluating and managing patients without physical examination, it is of utmost importance that practitioners protect themselves regarding the legal aspects regarding possible malpractice claims. The following type of disclaimer may be necessary:

1. That it should be communicated to the patient that this remote consultation is being provided under the unusual circumstances of the COVID-19 outbreak and lockdown of the country and that the patient should be aware of the limitations of such a consultation.
2. That the patient will not hold the practitioner liable for circumstances that may result from such limited access to the patient and that the patient is entering into such a consultation with full knowledge of such limitations.
3. The patient must be informed that that the service will be claimed from their scheme and / or from themselves.

Record keeping of the consultation and such an acknowledgement is of utmost importance. With the patient’s consent the consultation may be recorded, or a written consent may be obtained before the practitioner proceeds with such a telehealth consultation.

It is recommended that such a consultation happens on a scheduled appointment basis, before which such a disclaimer must first be agreed to.

It is also of utmost importance that practitioners realise that, because their practices are spaces where vulnerable people come to, the risk to patients in terms of COVID-19 infections could be fatal. It is therefore imperative that all the necessary precautions must be taken in order to prevent the transmission of the disease within the confines of their practices. But, to be on the safe side, practitioners should have patients sign disclaimers that would protect them from liability claims that may result from patients contracting the disease after a visit to the practice.

SAMA’s legal team will provide two disclaimers for practices to use: One for Telehealth consultations and one for face-to-face encounters with the doctor. These two disclaimers will be sent out for easy download as soon as possible.

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