Archive for May, 2020

Multisystem Inflammatory Syndrome in Children Associated with COVID-19

Posted by Samantha Serfass on May 28, 2020 in Blog, News

Multisystem Inflammatory Syndrome in Children Associated with COVID-19

As we have begun to see more and more cases of COVID-19, the majority of the more severe cases have been found to be in the elderly population or people with underlying chronic conditions affecting the ability of the immune system to fight illness.  We have yet to see many cases of confirmed COVID-19 in infants and children.  However, recently there have been reports of children and adolescents with a multisystem inflammatory condition with symptoms similar to those seen in Kawasaki disease and toxic shock syndrome and required admission to intensive care units.  It is thought that this multisystem inflammatory syndrome may be related to COVID-19. [1]

Kawasaki Disease

Kawasaki disease is an acute febrile illness usually occurring in children younger than 5 years of age.  The fever usually lasts at least 5 days and is associated with rash, swelling of the hands and feet, swollen lymph glands in the neck and irritation and inflammation of the mouth and throat.[2]

Toxic Shock Syndrome

Toxic shock syndrome is another condition that typically presents with a high fever.  Associated symptoms include hypotension, diffuse erythematous rash, and organ dysfunction in at least two organ systems that may progress rapidly to severe shock.  Toxic shock syndrome is typically caused by staphylococcal or streptococcal bacteria.[3]

On May 14, 2020, the Centers for Disease Control and Prevention (CDC) released an official health advisory which provided background information on several cases of multisystem inflammatory syndrome in children (MIS-C) associated with coronavirus disease 2019 (COVID-19) along with a case definition of the syndrome.  Cases have been reported in U.S. and other countries. [4]

Case Definition for Multisystem Inflammatory Syndrome in Children (MIS-C):

  • Age 21 years or younger presenting with fever
  • Laboratory evidence of inflammation
  • Evidence of clinically severe illness requiring hospitalization
  • Multisystem organ involvement (2 or more organ involvement)
  • No other plausible diagnosis
  • Positive for current or recent SARS-CoV-2 infection by RT-PCR, serology, or antigen test; or COVID-19 exposure within the 4 weeks prior to the onset of symptoms

The CDC is recommending that healthcare providers who have treated or are currently treating patients meeting the criteria for (MIS-C) should report suspected cases to their local, state, or territorial health department.[4]

Coding Guidance:

As of April 1, 2020, there is no official coding guidance for MIS-C.  MIS-C cannot be indexed in the ICD-10-CM Alphabetic Index therefore coders must follow the guidance in ICD-10-CM Official Guidelines for Coding and Reporting, Section I.B.15:  Syndromes.  This instructs the coder to assign codes for the documented manifestations of the syndrome.  Any additional symptoms that are not an integral part of the disease process may be reported when the condition does not have a unique code.

NOTE: Changes to the official coding guidelines and rules beyond April 1, 2020 will render the Coding Guidance educational content invalid for future educational purposes.

Sandy Hall, Coding Education Auditor; CCS, COC, CPC






Posted by Samantha Serfass on May 21, 2020 in Blog, News


As states across the US begin the process of reopening, establishing a sense of normalcy becomes a top priority. Healthcare systems are facing a significant challenge as they work to resume normal operations while still focusing efforts on decreasing the virus.

It is estimated the American healthcare system has lost $200 billion dollars resulting in the job loss of over 1.4 million healthcare workers. While healthcare systems begin to resume full services, several key factors are important to consider.

In March, the CMS first recommended limiting the non-essential care in an effort to save critical PPE supplies. As healthcare systems reopen and PPE supplies still remain limited, the CMS has updated its recommendations for facilities in order to allow health systems to safely provide nonemergent non-COVID-19 care. The CMS will continue to publish recommendations and updates to existing guidelines to help carefully phase in normal hospital operations. More information on the guidelines and regulations established by the CMS for phase one can be found here.

Healthcare IT departments have shifted gears to best assist their hospitals during COVID-19. Hospitals across the US have pressed “pause” on many projects unless considered critical – shifting their focus to support COVID-19 initiatives.

Tim Pugsley, CIO for Titus Regional Medical Center in Mount Pleasant, TX, has dispatched analytics, informatics and technical teams to support their clinical leaders across many platforms. They have created new dashboards which track PPE consumption rates, temperature tracking for staff, video visit encounters and record call center statistics for the CV-19 hotline.  In addition, they have updated their EHR to record the latest COVID-19 documentation requirements all while supporting a remote workforce.

TRMC has also expanded their telehealth presence. Prior to COVID-19, TRMC focused on telehealth equipment in the ambulances and extending specialty care to outlying communities. Since the pandemic, they have enabled video visits in TRMC operated and independent ambulatory clinics, inpatient floors and on the COVID unit. Patient’s visitors also have an option to become “virtual visitors” enabling them to interact with loved ones.

                 “We understand the importance of social interaction with family and friends. To address that need, we supply the patient with a tablet and technology to have a video interaction” added Pugsley.

While preparing to reopen, Telehealth initiatives are the front runners for helping to safely allow these healthcare systems to better assist, treat and safely diagnosis their patients while working to decrease the possibility for COVID-19 exposure. Titus Regional Medical Center’s clinical leaders are developing a strategy and tactical plans to safely provide care by partnering with physicians and key stakeholders. Policies and procedures are reviewed constantly to adapt to the changing landscape and processes continue to evolve to support our community, our providers, and our staff.

As elective services begin to slowly reopen, Titus has leveraged their telehealth solution to keep the community informed. Through the use of MyChart, public radio and social media platforms – like Facebook – Titus has been able to communicate with the community about the virus, guidelines, and regulations being implemented.

Telehealth will continue to play a vital role as phase one of reopening begins to occur. CMS will likely start to remove the waivers they once had in place for telehealth solutions (for example, enforcing HIPAA compliance). Ensuring your telehealth solution is effective and compliant is more crucial than ever. Demonstrated by TRMC, telehealth solutions allow healthcare systems to safely and efficiently communicate, treat, and assist patients during this pandemic.

Excite Health Partners offers the knowledge and experience to implement the right fit telehealth solution. We can develop new workflows and data integration, improve the efficiency of care and help recover revenue. As healthcare systems continue to adapt during these unprecedented times, we can help ease the burden of implementing the best telehealth solution to meet your organization’s needs.

Todd Klein, CIO, VP of EHR Services & Digital Solutions

COVID-19 and Cytokine Storm/Cytokine Release Syndrome (CRS)

Posted by Samantha Serfass on May 6, 2020 in Blog, News

COVID-19 and Cytokine Storm/Cytokine Release Syndrome (CRS)

During this COVID-19 crisis, coders are beginning to see the providers document cytokine storm as a secondary diagnosis in patients who have been diagnosed with a primary diagnosis of COVID-19.

Some of the acutely ill COVID-19 patients are developing a cytokine storm which is a Cytokine Release Syndrome (CRS). The sickest patients are the ones who have CRS that can lead to the patient developing secondary hemophagocytic lymphistiocytosis (sHLH) which then causes the patient to develop acute respiratory distress syndrome (ARDS).1

CRS “is caused by a large, rapid release of cytokines into the blood from immune cells” “Cytokines are immune substances that have many different actions in the body.” In some patients, excessive or uncontrolled levels of cytokines are released which then activate more immune cells, resulting in hyperinflammation. It is the overreaction of the immune system.

Coders and CDI Specialists should be very careful when querying the provider for clarification of cause of the signs/symptoms and/or clinical indicators for appropriate code assignment. 1,2 The symptoms of CRS can mimic other conditions.

Cytokine storms can be seen in the below conditions which have similar pathophysiology but have very different treatment options. Therefore, it is imperative to capture the conditions correctly through coding.

  • Sepsis
  • Non-infectious SIRS
  • Macrophage activation syndrome (MAS)
  • Secondary hemophagocytic lymphohistiocytosis

Possible Signs/Symptoms of CRS:

  • Trouble breathing
  • Low blood pressure
  • Rapid heart rate
  • Fever
  • Headache
  • Nausea
  • Rash
  • Multi-organ dysfunction – in severe cases

Possible Laboratory Clinical Indicators of CRS:

  • Elevated serum ferritin2
  • Markedly increased interleukin-6 (IL-6)2
  • High levels of C-reactive protein2
  • Elevated blood nitrogen levels5
  • Elevated D-dimer5

Coding Guidance:

Currently, as of April 1, 2020, neither CRS nor cytokine storm can be indexed in the ICD-10-CM code book.

Per the AHA Coding Clinic for ICD-10-CM/PCS, Second Quarter 2019 Pages 24-25, and First Quarter 2020 Page 37, with there not being a specific code for CRS and it cannot be indexed in the code book, coders must follow the ICD-10-CM Official Guidelines for Coding and Reporting Section I.B.15 Syndromes where there are instructions to code the manifestations of the syndrome based on physician documentation. Any additional manifestations that are not typically integral to the condition may also be assigned if the condition does not have its own unique code. 4

NOTE: Changes to the official coding guidelines and rules beyond April 1, 2020 will render the Coding Guidance educational content invalid for future educational purposes.

Lorrie Strait, RHIT, CCS

Manager HIM Services, Excite Health Partners


  2., April 8, 2020
  4. AHA Coding Clinic for ICD-10-CM/PCS, Second Quarter 2019 Pages 24-25, and First Quarter 2020 Page 37
  5. Merck Manual,