Capturing COVID-19 Diagnoses Using interRAI Assessments in Long-Term Care, Home Care and Inpatient Mental Health

April 2, 2020 — COVID-19 (coronavirus disease) is caused by a new strain of coronavirus not previously identified in humans. It was first detected in Wuhan, China.

Coronaviruses (CoV) are a large family of viruses that cause illness ranging from the common cold to more severe diseases such as Middle East Respiratory Syndrome coronavirus (MERS-CoV) and Severe Acute Respiratory Syndrome–associated coronavirus (SARS-CoV).

COVID-19 diagnoses can be captured during the completion of interRAI assessments used in continuing care and long-term care settings, home care and inpatient mental health facilities.

ICD-10-CA coding direction

  • Confirmed cases of COVID-19 in Canada are assigned the following ICD-10-CA diagnosis code: U07.1 Emergency use of U07.1 (COVID-19, virus identified).
  • Suspected cases of COVID-19 in Canada are assigned the following ICD-10-CA diagnosis code: U07.2 Emergency use of U07.2 (COVID-19, virus not identified).

Record the ICD-10-CA diagnosis codes for confirmed or suspected cases of COVID-19 at the time of assessment using the following assessment items:

Continuing care and long-term care

  • interRAI LTCF: I2 Other Disease Diagnoses
  • RAI-MDS 2.0: I3 Other Current Diagnoses and ICD-10-CA Codes

Home care

  • interRAI CA: D6 Disease Diagnoses
  • interRAI HC: I2 Other Disease Diagnoses
  • RAI-HC: J2 Other Current or More Related Diagnoses and ICD-10-CA Codes

Inpatient mental health

  • RAI-MH: I11 Medical Diagnoses

Capturing other relevant clinical information for COVID-19

In addition to capturing diagnosis codes for confirmed or suspected cases, include clinical information that is present and relevant in the context of COVID-19 using the appropriate sections of the assessment. This may include, but is not limited to, the following:

  • Signs and symptoms
    Dyspnea (shortness of breath), pain, fatigue, fever, instability of conditions
  • Comorbid conditions
    Coronary artery disease, chronic obstructive pulmonary disease, pneumonia, diabetes mellitus, hypertension
  • Treatment and other interventions
    Infection control (interRAI LTCF and interRAI HC only), oxygen therapy (respiratory therapy), hospital use, emergency room use, physician visits

Explore CIHI’s COVID-19 resources web page, with key reports and resources on the coronavirus disease (COVID-19) pandemic.

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