COVID Guidelines Update
As of April 2025, documentation of a positive COVID-19 test alone no longer confirms a diagnosis of COVID-19. Provider documentation is REQUIRED. Note the verbiage that has been removed from the Official Guidelines for Coding and Reporting.
Code only confirmed cases:
Code only a confirmed diagnosis of the 2019 novel coronavirus disease (COVID-19) as documented by the provider, or documentation of a positive COVID-19 test result. For a confirmed diagnosis, assign code U07.1, COVID-19. This is an exception to the hospital inpatient guideline Section II, H. In this context, “confirmation” does not require documentation of a positive test result for COVID-19; the provider’s documentation that the individual has COVID-19 is sufficient.
Asymptomatic individuals who test positive for COVID-19:
For asymptomatic individuals who test positive for COVID-19 and there is no provider documentation of a diagnosis of COVID-19, query the provider as to whether or not the individual has COVID-19. A false positive laboratory test is possible, and it is the provider’s responsibility to confirm the diagnosis and document accordingly. see guideline I.C.1.g.1.a. Although the individual is asymptomatic, the individual has test positive and is considered to have the COVID-19 infection.
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e4health Coding Education
Kim Felix, RHIA, CCS
Director of Education
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kfelix@e4.health
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Coding Operations Manager
(216) 501-2058
lharbison@e4.health
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