ACDIS tip: Cytokine release syndrome due to COVID-19

by Karla Accorto

It has been over a year since the World Health Organization declared COVID-19 a pandemic. Since then, physicians and scientists alike have learned so much about the virus, both proving and disproving commonly held theories. For example, it seemed obvious from that start is that COVID-19 affected each person differently—some people never even knew they had the virus, while others ultimately died from it. Studies have shown that part of this discrepancy is due to certain complicating conditions or comorbidities (CC) that a person may have.

According to the Centers for Disease Control and Prevention, 62% of hospitalized COVID-19 patients had one of five ICD-10-CM diagnosis codes upon admission:

• Chronic obstructive pulmonary disease
• Heart failure
• Diabetes mellitus type 1 or 1
• Chronic kidney disease
• Obesity

Additionally, the National Institutes of Health reported that those with cardiovascular conditions, hypertension, diabetes, and chronic lung conditions are more likely to experience a worse prognosis and a greater risk of mortality.

While not as common as those CCs previously mentioned, cytokine release syndrome (CRS) is another CC that can be affected by a COVID-19 infection. As Dawn Valdez, RN, LNC, CDIP, CCDS, recently explained during a PROPEL CDI education session on COVID-19 and CCs, CRS occurs when too many cytokines enter the bloodstream, provoking a cellular response that can lead to organ disfunction and, in some cases, death. Patients with mild cases often present with flu like symptoms such as fever, fatigue, and headache, while patients with severe cases may present with hypotension, high fever, and a systemic inflammatory response similar to that elicited by sepsis or multiorgan failure.

CDI specialists may wish to query for a potential CRS diagnosis if the following indicators are documented but a CRS diagnosis is not:

• Leukocytosis or leukopenia
• Abnormal renal and liver function
• Elevated levels of c-reactive protein, ferritin, interferon gamma, interleukin [IL]-6, IL-10, or soluble IL-2R alpha

In order for a CRS diagnosis to be considered, however, the patient’s fever must not be attributable to any other diagnosis or cause.

An additional query opportunity is present if a physician documents a cytokine storm. This is common terminology among providers, but it is not in the coding index and therefore cannot manifest as an ICD-10 code. CDI specialists should instead query for a CRS diagnosis.

Furthermore, when a patient is admitted for treatment of CRS due to COVID-19, COVID-19 should be coded as the principal diagnosis, and CRS should be coded as the secondary diagnosis. The underlying cause of the CRS is always coded first followed by an additional code for the CRS grade. CDI specialists should note that that CRS grades three, four, and five count as CCs, so they should query for the grade as needed. If your organization does not have a specific CRS grading system, CDI specialists should consider advocating for one. Coding Clinic, fourth quarter 2020, p. 12, includes the following grading system:

Additionally, CDI specialists should validate the documented grade against the indicators in their facility’s preferred grading system and query the provider if there is a conflict.

As always seems to be the case with CDI, querying is essential. Simply put, the best way to avoid claim denials and ensure appropriate reimbursement is to identify and act upon all query opportunities.

Editor’s note: Accorto is a PROPEL CDI member liaison. For more information about PROPEL CDI, please contact Julie McCoy (jccoy@hcpro.com).