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Coding Long COVID
Tips for finding the correct codes:
Research published in England suggests that there is a lot of under-reporting of Long COVID, possibly because the codes are new and unfamiliar, or because it’s unclear when to use them. This table outlines the definitions of long COVID (according to NICE), which codes to use, and the keywords which help to locate the codes easily.
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Coding Long COVID
Use the pathway below to structure your consultation with a patient presenting with neurological symptoms associated with Long COVID.
Presenting symptoms:
It is not clear why patients have persistent neurological symptoms associated with Long COVID. In common with other coronaviruses SARS-CoV-2 does exhibit some neurotropism but it is relatively rare for the central or peripheral nervous system to be severely and persistently affected.
3 questions to include in the history:
Patients who required a prolonged stay on an intensive care unit may experience significant deconditioning, and in some a neuromyopathy occurs which can hamper recovery, or in some be the main cause of impaired mobility.
The presence of one or more red flag features or symptoms may indicate a significant complication of Long COVID, or the emergence or worsening of a co-morbidity.
Features of long-COVID
The standard neurological examination starts with higher function, cranial nerves, and examination of the limbs
In general, despite some patients reporting a marked reduction in stamina and exercise tolerance, it is unusual to detect neurological signs on examination.
Routine blood tests
Routine blood tests including FBC, U&Es, glucose, calcium, thyroid function, LFT, vitamin D, B12 and folate, should be requested for any patient presenting with malaise and fatigue.
More detailed neurological tests
Patients referred to neurology clinics for unexplained, persistent symptoms, may go on to have more detailed neurological testing.
Highly likely to be explained by long-COVID:
Patients with typical symptoms of Long COVID can be reassured that their journey of recovery is normal.
Proceed to step 6 to determine which patients might benefit from a referral to a Long COVID multidisciplinary rehabilitation service, and which can be managed at home with support of the COVID recovery app.
Self-management, with the support of the NHS Wales COVID recovery app
The COVID recovery app supports the patient with:
Referral to multidisciplinary rehabilitation services
Consider referral if:
Refer to specialist neurology clinic
Consider referral if:
For most patients, the road to recovery begins by acknowledging how unwell they have been, validating their experience with a healthcare professional, and accepting that they have a post-viral syndrome. There might be fluctuations in recovery, but the vast majority of people make a gradual recovery and will get better.
Armed with this knowledge, some patients will be happy to proceed with self-management, while others may need some further holistic support by the multidisciplinary rehabilitation services for long COVID. Details of this team in your area can be found below.
In order to view the Long COVID services available in your area, please complete your profile here
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Coding Long COVID
Use the pathway below to structure your consultation with a patient presenting with respiratory symptoms associated with Long COVID.
Presenting symptoms:
The aetiology for these symptoms may simply be down to deconditioning or hyperventilation. However, there are a some organic illnesses that are recognised as a consequence of acute COVID infection, including chronic cough, bronchiectasis, pulmonary fibrosis, and pulmonary vascular disease.
3 questions to include in the history:
The presence of one or more red flag features or symptoms may indicate a significant complication of Long COVID, or the emergence or worsening of a co-morbidity.
Features of long-COVID
The standard respiratory examination should include oxygen saturations, checking for ankle swelling, finger clubbing, assessing JVP, tachycardia, and chest auscultation.
Typically, patients with Long COVID will have no remarkable findings on respiratory examination
Further investigations may be required, dictated by the deficits described by the patient.
Chest x-ray
Every patient with continuing respiratory symptoms after 12 weeks should have a chest x-ray (NICE).
Spirometry
To rule out any obstructive abnormalities (FEV1/FVC<0.7) or restrictive abnormalities (abnormally reduced FVC).
Pulse oximetry
If pulse oximetry at rest is normal, ask the patient to do a simple exercise tolerance test to monitor for desaturations.
Highly likely to be associated with long-COVID:
Patients with typical symptoms of Long COVID can be reassured that their journey of recovery is normal.
Proceed to step 6 to determine which patients might benefit from a referral to a Long COVID multidisciplinary rehabilitation service, and which can be managed at home with support of the COVID recovery app.
Self-management, with the support of the NHS Wales COVID recovery app
Patients are coping well and are happy to continue with some self-management advice.
The COVID recovery app supports the patient with:
Referral to multidisciplinary rehabilitation services
Consider referral if:
Refer to specialist respiratory clinic
Consider referral if:
For most patients, the road to recovery begins by acknowledging how unwell they have been, validating their experience with a healthcare professional, and accepting that they have a post-viral syndrome. There might be fluctuations in recovery, but the vast majority of people make a gradual recovery and will get better.
Armed with this knowledge, some patients will be happy to proceed with self-management, while others may need some further holistic support by the multidisciplinary rehabilitation services for long COVID. Details of this team in your area can be found below.
In order to view the Long COVID services available in your area, please complete your profile here
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Coding Long COVID
Use the pathway below to structure your consultation with a patient presenting with cardiac symptoms associated with Long COVID.
Presenting symptoms:
There are a some cardiac sequelae of acute COVID infection, including arterial and venous thrombosis, heart muscle inflammation and autonomic dysfunction.
3 questions to include in the history:
The presence of one or more red flag features or symptoms, may indicate a significant complication of Long COVID, or the emergence of a co-morbidity.
Features of long-COVID
The standard cardiac examination should include blood pressure, pulse, and perfusion status.
Typically, patients with Long COVID will have no remarkable findings on cardiac examination
Further investigations may be required, dictated by the deficits described by the patient.
12-lead ECG
A resting 12-lead ECG is useful to identify abnormality.
Blood tests
Blood tests including full blood count, electrolytes, and BNP.
Chest x-ray
Looking for signs of fluid congestion.
Highly likely to be explained by long-COVID:
Patients with typical symptoms of Long COVID can be reassured that their journey of recovery is normal.
Proceed to step 6 to determine which patients might benefit from a referral to a Long COVID multidisciplinary rehabilitation service, and which can be managed at home with support of the COVID recovery app.
Self-management, with the support of the NHS Wales COVID recovery app
Patients are coping well and are happy to continue with some self-management advice.
The COVID recovery app supports the patient with:
Referral to multidisciplinary rehabilitation services
Consider referral if:
Refer to specialist cardiology clinic
Consider referral if:
For most patients, the road to recovery begins by acknowledging how unwell they have been, validating their experience with a healthcare professional, and accepting that they have a post-viral syndrome. There might be fluctuations in recovery, but the vast majority of people make a gradual recovery and will get better.
Armed with this knowledge, some patients will be happy to proceed with self-management, while others may need some further holistic support by the multidisciplinary rehabilitation services for long COVID. Details of this team in your area can be found below.
In order to view the Long COVID services available in your area, please complete your profile here
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Coding Long COVID
Use the pathway below to structure your consultation with a patient presenting with psychological symptoms associated with Long COVID.
Presenting symptoms:
There are little data on long term psychological sequelae in COVID-19, especially in those with Long COVID. Adults are more likely to be diagnosed with psychiatric conditions including anxiety and depression, and this is often associated with persistent physical symptoms such as breathlessness and myalgia.
3 questions to include in the history:
The presence of one or more red flag features or symptoms may indicate a significant complication of Long COVID, or the emergence or worsening of a co-morbidity.
GAD-7 scoring system
A tool for assessing anxiety in practice.
PHQ-9 scoring system
A tool for assessing depression in practice.
Impact of events scale for assessing trauma
Assessing Psychological Trauma and PTSD.
Self-management, with the support of the NHS Wales COVID recovery app
Patients are coping well and are happy to continue with some self-management advice.
The COVID recovery app supports the patient with:
Referral to multidisciplinary rehabilitation services
Consider referral if:
Refer to specialist psychology clinic
Consider referral if:
For most patients, the road to recovery begins by acknowledging how unwell they have been, validating their experience with a healthcare professional, and accepting that they have a post-viral syndrome. There might be fluctuations in recovery, but the vast majority of people make a gradual recovery and will get better.
Armed with this knowledge, some patients will be happy to proceed with self-management, while others may need some further holistic support by the multidisciplinary rehabilitation services for long COVID. Details of this team in your area can be found below.
In order to view the Long COVID services available in your area, please complete your profile here
Healthboard not selected
Coding Long COVID
Use the pathway below to structure your consultation with a patient presenting with dermatological symptoms associated with Long COVID.
Presenting symptoms:
Since the start of the COVID-19 pandemic, the dermatological manifestations of Long COVID have been reported, however, data on duration of signs and symptoms are lacking.
Most rashes associated with COVID-19 do not require treatment and will resolve within a few days/ weeks.
Video 1: Overview of psychological symptoms
Video 2: Management and referral
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3 questions to include in the history:
Features of long-COVID
Self-management, with the support of the NHS Wales COVID recovery app
The COVID recovery app supports the patient with:
Referral to multidisciplinary rehabilitation services
Consider referral if:
Refer to specialist dermatology clinic
Consider referral if:
For most patients, the road to recovery begins by acknowledging that they have a post-viral syndrome and that recovery can take time. There might be fluctuations in recovery, but the vast majority of people make a gradual recovery and will get better.
In order to view the Long COVID services available in your area, please complete your profile here
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Coding Long COVID
Use the pathway below to structure your consultation with a patient presenting with ENT symptoms associated with Long COVID.
Presenting symptoms:
It is not clear why patients have persistent ear, nose and throat symptoms following infection with COVID-19, but the upper airway is one of the main sources of transmission of infection.
3 questions to include in the history:
Symptoms persist for longer than 3 months.
Problematic, persistent globus or throat sensitivity.
Difficulty with chewing and swallowing, choking episodes, persistent coughing and throat clearing.
Signs and symptoms of sinonasal malignancy include loss of sense of smell, unilateral nasal obstruction, visible unilateral mass, unilateral bloody nasal discharge, facial paraesthesia and facial swelling, and diplopia.
USC referral to ENT for endoscopy and investigation.
Signs of Upper Aerodigestive Tract Cancer include difficulty swallowing, sore throat, dysphonia, voice change, progressive difficulty swallowing, neck mass, weight loss, particularly if the symptoms are progressive and continuing for more than 3 weeks.
USC referral to ENT for nasal endoscopy and further investigation.
Signs of sudden onset sensorineural hearing loss include sudden reduction/loss of hearing with no clinical cause identified. Tuning fork: Webers test to contralateral side, and Rinne positive on contralateral (beware false negative ipsilateral).
Commence oral steroids as soon as possible (40mg Prednisolone OD 1/52). Refer to ENT on-call for expedited investigation and ongoing management.
Signs and symptoms of Vestibular Schwannoma (Acoustic Neuroma) include generally gradual progressive unilateral hearing loss (can present with sudden onset in 10%), unilateral tinnitus, but examination of the ears is normal.
Refer to ENT for assessment of ears/hearing and further investigation as appropriate (can be triaged routine).
Features of long-COVID
COVID-related ENT conditions:
Sensorineural Anosmia – loss or change to sense of smell without signs or symptoms of sinonasal pathology or other identifiable cause. Reassure patient that post-URTI anosmia can take up to two years to settle, and a trial of prednisolone for 2-3/52 can be considered. Refer to ENT for further investigation (routine) or more urgently if other clinical features are present.
Chronic Rhinosinusitis – nasal obstruction/congestion or nasal discharge, facial pain/pressure, hyposmia/anosmia, discharge anteriorly/tracking to oropharynx, inflamed congested mucosa, nasal polyps. Consider nasal douching/Sterimar and Nasal steroid inhaler, and consider course of antibiotics. Refer to ENT if no improvement.
Laryngeal trauma/inflammation – dysphonia, clear history of onset as result of URTI/ repeated coughing, no other features of UAT malignancy. Commence Gaviscon Advance 10ml QDS plus PPI. Refer to ENT if no improvement, but refer as USC straightaway if malignancy is suspected.
Vestibular Hypofuction – imbalance or unsteadiness on feet, caused by poor compensation post vestibular insult (post-labyrinthitis; URTI). Refute neurological cause (confirm peripheral deficit), Cooksey-Cawthorne exercises, refer to ENT.
Self-management, with the support of the NHS Wales COVID recovery app
The COVID recovery app supports the patient with:
Referral to multidisciplinary rehabilitation services
Consider referral if:
Refer to specialist ENT clinic
Consider referral if:
For most patients, the road to recovery begins by acknowledging that they have a post-viral syndrome and that recovery can take time. There might be fluctuations in recovery, but the vast majority of people make a gradual recovery and will get better.
In order to view the Long COVID services available in your area, please complete your profile here
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Coding Long COVID
Use the pathway below to structure your consultation with a patient presenting with musculoskeletal symptoms associated with Long COVID.
Presenting symptoms:
An abnormal, exaggerated inflammatory response, as well as periods of inactivity, appears to be the key mechanism for the variety of musculoskeletal features of Long COVID.
3 questions to include in the history:
Features of long-COVID
Self-management, with the support of the NHS Wales COVID recovery app
The COVID recovery app supports the patient with:
Referral to multidisciplinary rehabilitation services
Consider referral if:
Refer to specialist rheumatology clinic
Consider referral if:
For most patients, the road to recovery begins by acknowledging that they have a post-viral syndrome and that recovery can take time. There might be fluctuations in recovery, but the vast majority of people make a gradual recovery and will get better.
In order to view the Long COVID services available in your area, please complete your profile here
Healthboard not selected
Coding Long COVID
Use the pathway below to structure your consultation with a patient presenting with gastrointestinal symptoms associated with Long COVID.
Presenting symptoms:
Emerging data suggest that the GI tract and liver might be affected by SARS-CoV-2, on the basis that epithelial cells and liver cells express ACE2, the major receptor of SARS-CoV-2.
3 questions to include in the history:
The presence of red flag features or symptoms may indicate a significant complication of Long COVID, or the emergence or worsening of a co-morbidity.
Routine blood tests
Routine blood tests including FBC, U&Es, glucose, calcium, thyroid function, LFT, ferritin, B12 and folate, should be requested for any patient presenting with Long COVID and GI symptoms.
Self-management, with the support of the NHS Wales COVID recovery app
The COVID recovery app supports the patient with:
Referral to multidisciplinary rehabilitation services
Consider referral if:
Refer to specialist secondary care
Consider referral if:
For most patients, the road to recovery begins by acknowledging that they have a post-viral syndrome and that recovery can take time. There might be fluctuations in recovery, but the vast majority of people make a gradual recovery and will get better.
In order to view the Long COVID services available in your area, please complete your profile here
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