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Zika
Virus - A Q&A Primer
by Lori-Lynne A.
Webb, CPC, CCS-P, CCP, CHDA, COBGC, CDIP
What is Zika?
According to the Center for Disease Control
(CDC) this is the official
definition:
The Zika virus is a mosquito-transmitted
infection related to dengue, yellow fever and West Nile virus. It was
discovered in the Zika forest in Uganda in 1947 and is common in Africa and
Asia. It did not begin spreading widely
in the Western Hemisphere until last May, when an outbreak occurred in Brazil.
A bit of clinical background
This is information direct from the American
Congress of Obstetricians and Gynecologists (ACOG) and the Society of Maternal and Fetal
Medicine (SMFM)
The virus spreads
to humans primarily through infected Aedes aegyti mosquitoes. Once a person is
infected, the incubation period for the virus is approximately 3-12 days.
Symptoms of the disease are non-specific but may include fever, rash,
arthralgias, and conjunctivitis. It appears that only about 1 in 5 infected
individuals will exhibit these symptoms and most of these will have mild
symptoms. It is not known if pregnant women are at greater risk of infection
than non-pregnant individuals.
Zika during
pregnancy has been associated with birth defects, specifically significant
microcephaly. Transmission of Zika to the fetus has been documented in all
trimesters; Zika virus RNA has been detected in fetal tissue from early missed
abortions, amniotic fluid, term neonates and the placenta. However, much is not
yet known about Zika virus in pregnancy. Uncertainties include the incidence of
Zika virus infection among pregnant women in areas of Zika virus transmission,
the rate of vertical transmission and the rate with which infected fetuses
manifest complications such as microcephaly or demise. The absence of this
important information makes management and decision making in the setting of
potential Zika virus exposure (i.e. travel to endemic areas) or maternal
infection, difficult. Currently, there is no vaccine or treatment for this
infection.
The ACOG and SMFM put forth guidelines for testing
of pregnant women, and the laboratory tests are being done exclusively though
the guidance of the CDC at the level of the local and state health departments. Many states in the US are developing
guidelines to help in identifying who has been exposed, and where an outbreak
may take place.
Currently the testing being done is a “Zika”
serology IgM testing assay. The reports
have been being reported out as “likely positive”, “Inconclusive” and “likely
negative” . Unfortunately, the labs do not know and
gannot guarantee the sensitivity of the IgM assay.
Symptoms of Zika
Below is a
listing of all the known symptoms of Zika virus as put forth by the CDC,
however, there may be more that are noted as the Zika Virus becomes more
studied in all individuals. Zika is still a virus, and not a bacterial
infection, and currently there is not vaccine to prevent it, or a specific medication
or antibiotic to treat it with.
• About 1 in 5
people infected with Zika virus become ill (i.e., develop Zika).
• The most common
symptoms of Zika are fever, rash, joint pain, or conjunctivitis (red eyes).
Other common symptoms include muscle pain and headache. The incubation period
(the time from exposure to symptoms) for Zika virus disease is not known, but
is likely to be a few days to a week.
• The illness is
usually mild with symptoms lasting for several days to a week.
• People usually
don’t get sick enough to go to the hospital, and they very rarely die of Zika.
• Zika virus
usually remains in the blood of an infected person for about a week but it can
be found longer in some people.
Risks of Zika in Pregnant Women and in their sexual partners
Normally Zika virus is transmitted through a
mosquito bite, however, the Zika virus can be transmitted from a pregnant
mother to her unborn fetus during the time of pregnancy and possibly around the
time of birth. It has been noted that
Zika virus has been noted in all trimesters of pregnant women, and may possibly
be transmitted during the birth process.
Sexual transmission of the Zika virus can also occur, however there is
limited data, but the CDC has stated that if the patient fears they are
infected with the Zika virus to reduce the risk of sexual transmission via
abstinence and/or usage of condoms.
Women are not the only ones at risk of contracting
Zika virus. Men who have traveled to an
area of active Zika virus, or who live in these areas may become infected with
the Zika virus too. The CDC has not
completely determined if the Zika virus can be transmitted sexually, so the
recommendation for men is if you are symptomatic or have a confirmed case of
Zika virus, condoms or abstinence is still a best practice. However, it remains uncertain if the mirus
persisits in semen even if no longer detectible in the blood.
Fetal Evaluation for possible exposure to Zika
Ultrasound exami is the primary recommendation for
pregnant mothers who have been exposed to zika virus. The Ultrasound examinations should focus on
development of the fetal brain with intracranial calcifications and
microcephaly. Micocephay has been the
most frequently reported adverse fetal complication in women who have had the virus while
pregnant
SMFM is recommending not only blood tests for
pregnant women who have been exposed, but also consider performing serial
ultrasound, as frequently as every 3-4 weeks.
By obtaining the additional ultrasounds, this would be considered
ongoing surveillance. Considering the
history of Zika virus and complications to the fetus due to this infection is not known. In addition, the time from exposure and infection from Zika
to exhibiting full-blown clinical manifestations
is unknown.
The CDC, ACOG and SMFM have put out a number of
clinical flow algorhythms for usage with patients’ that have been exposed or
live in an area where Zika as been prevalent.
However, this is so new, that these recommendations may change very
quickly.
Case Study and Coding Consideration
Case #1:
An asymptomatic
pregnant woman at 19 weeks gestation, presents to her OB office for her
regularly scheduled OB prenatal visit. She
informs the receptionist of the possibility she has been exposed to Zika. She
has a history of travel to Mexico between 16+0 and 16+5-weeks. She has noted
mosquito bites over both legs (calf area).
The bites do not appear infected, and look as if they are
resolving. Patient states they no longer
itch, and does not report any other complaints but her ongoing pregnancy
related fatigue. The physician performs
a comprehensive history, a comprehensive exam, and will have labs drawn for
Zika to be sent to the local district health office. In addition, the physician decides to perform
a baseline screening ultrasound exam to follow up from the patient’s first
trimester ultrasound anatomy exam from 1 month ago.
Coding
Consideration:
CPT:
99214-25 E&M -
76816 Ultrasound
36415 Venipuncture/Lab Draw
ICD-10:
O26.812 Pregnancy related exhaustion and fatigue (2nd
trimester)
Z20.828 Contact with and (suspected) exposure to
other viral communicable diseases
(Zika Virus)
S80.861A Insect bite of rt lower leg initial encounter
S80.862A Insect bite of lt lower leg initial encounter
Z3A.19 19 weeks gestation of pregnancy
Rationale: The
E&M visit would be coded, as it is separately identifiable “outside” the normal pregnancy antenatal
care. (A Zika virus exposure is not
considered “normal obstetric care”) the
follow-up ultrasound/baseline ultrasound is coded for comparison to the
previously performed 1st trimester ultrasound. The venipuncture is the only thing
chargeable, as the blood was drawn, and sent out to the health district for
testing. The sequencing of the pregnancy
diagnosis is primary based upon the ICD-10 pregnancy guidelines.
ACOG’s Quick Zika Q&A
Q1. True or False. Pregnant women are at greater
risk of infection with the Zika virus than nonpregnant women.
A: False - According to a practice advisory
from ACOG and SMFM, “It is not known if pregnant women are at greater risk of
infection than non-pregnant individuals.”
Q2. Once a person is infected with the Zika
virus, what is the approximate incubation period for the virus?
A:. 3 to 12 days - Following infection with the
Zika virus, the incubation period is approximately 3 to 12 days
Q3.
The
Zika virus spreads to humans primarily through infected Aedes aegypti
mosquitoes. Which of the following symptoms may be associated with the virus?
Fever
Rash
Arthralgia
Conjunctivitis
All
of the above
A.
Although symptoms associated with the Zika virus
are non-specific, they may include fever, rash, arthralgia, and conjunctivitis.
(eg all of the above)
Q4. In which
trimester(s) has transmission of Zika been documented?
A. All trimesters
-- The transmission of the Zika virus has been documented in all trimesters
Wrap up
At this time, there are still a number of
unanswered questions in regard to the Zika virus. However, there is no vaccine currently
available, so it is recommended that precaution be taken to avoid exposure to
mosquito bites from areas where the Zika virus is prevalent. In the United States and worldwide expert
epidemiologists are helping to set forth useful clinical guidelines for
identifying and managing patients who have been exposed and currently have the
Zika virus. At this time, clinical
guidelines are calling for blood tests to be run, and screening ultrasound
should be performed on pregnant patients to screen for possible fetal anomalies
related to fetal brain development in infected female patients.
When coding, carefully review to see if the
physician or provider is stating whether the patient truly has the Zika virus
as a diagnosis, or if they are only “screening” for the Zika virus in light of
an exposure to the virus. (either through mosquito bite, or sexual
transmission).
In addition, currently, ICD-10 does not have a
specific code to identify Zika virus. Usage of code B33.8 Other specified
viral diseases, would be appropriate.
However, If the patient is diagnosed with the Zika virus and has fever
with it, then it may be appropriate to use code A92.8 – Other specified
mosquito-borne viral fevers. If the
patient is pregnant, then usage of ICD-10 code 098.5X “other viral
diseases complicating pregnancy, childbirth and the puerperium,” (be
sure to use the most specific trimester as the additional character) would be
the most appropriate.
If in doubt about the clinical documentation, be
sure to query the provider to obtain clarity on the diagnosis noted in the
medical record.
References:
www.acog.org/
www.cdc.gov/zika
Editor’s note: Lori-Lynne A. Webb, CPC, CCS-P,
CCP, CHDA, CDIP, COBGC and ICD10 cm/pcs Ambassador/trainer is an E&M, and
Procedure based Coding, Compliance, Data Charge entry and HIPAA Privacy
specialist, with over 20 years of experience.
Lori-Lynne’s coding specialty is OB/GYN office & Hospitalist
Services, Maternal Fetal Medicine, OB/GYN Oncology, Urology, and general
surgical coding. She can be reached via
e-mail at webbservices.lori@gmail.com or you can also find current
coding information on her blog site: http://lori-lynnescodingcoachblog.blogspot.com/.
