COVID-19 TEXT

Record the applicable code and associated date in this text field as described below. Also record information related to cancer treatment modifications in this field.

Choose U07.1 when patient meets criteria for coding below.

Code the appropriate date using the instructions when patient is eligible for code U07.1.

Instructions for recording ICD diagnosis codes

1. Code only a confirmed diagnosis of the 2019 novel coronavirus disease (COVID-19) as documented by a medical provider.
   1. Record code U07.1 for a confirmed diagnosis
      1. In this context, “confirmation” does not require documentation of the type of test performed; the provider’s documentation that the individual has COVID-19 is sufficient.
   2. In addition, record code U07.1 when the code was used for diagnosis within the facility EHR, in the hospital discharge, or as a contributing or underlying cause of death.
2. Record code U07.1 for a lab confirmed asymptomatic patient
3. Do not record code U07.1 when the provider documents "suspected," "possible," "probable," or “inconclusive” any wording of a suspicion of COVID-19
4. Registrars are not required to record codes for acute respiratory illness associated with COVID-19 (e.g., pneumonia), exposure to COVID, screening for COVID, signs and symptoms without a definitive diagnosis.
   1. Two lung injury patterns are noted – DAD/ARDS and a thrombotic/vasculitis-like picture
5. Record the date of confirmed diagnosis [test date (preferred) or office visit date]. Alternatively, record the hospital admission date, or lastly, the hospital discharge date.

Example of abstracting

Example: U07.1 [date: mm/dd/yyyy]

Diagnosis, staging or Treatment DELAYED due to COVID-19 (Z75.3)

Date of delay for Diagnosis, staging or Treatment due to COVID-19

First course of treatment changed due to COVID-19

Instructions for recording cancer treatment information.

It is always preferable to abstract information about treatment in the treatment text fields (i.e., RX Text). However, information about specific treatment modalities may not be available and the only available information is about treatment in general with no mention of a specific procedure. For this scenario, use the abstraction rules below.

Note: Record the following information for all cancer patients (when applicable) regardless of whether or not they have a COVID-19 diagnosis or test.

1. When first course of treatment was modified because of COVID-19 and no other specific details are provided in the Rx Text fields, record
   1. FCOT CHG D/T COVID-19 [first course of treatment changed due to COVID-19]
2. When diagnosis, staging, treatment (any modality), or other cancer management events have been delayed because of limited access to facilities or postponement of non-essential procedures due to COVID-19, abstract the date of decision to postpone and the Z75.3 code Z75.3 mm/dd/yyyy [unavailability or inaccessibility of health care facilities]
3. The abstracter can use both FCOT and Z75.3 at the same time. This combo is required when multiple steps of cancer management (diagnosis, staging, treatment modalities) were affected by unavailability or inaccessibility of oncology care.
4. No recording is necessary when the first course of treatment was not delayed, rescheduled or otherwise modified because of the COVID pandemic.