Breathe Easy When Coding Acute Bronchiolitis
Put your diagnosis coding skills to the test with this ED patient encounter.
CHIEF COMPLAINT: Increased work of breathing
HISTORY OF PRESENT ILLNESS: Trish is a 3-month-old girl brought in by her mom, who stated she started getting ill about a week ago. Her mother reports she’s been using a vaporizer and thinks it has helped. The patient’s cough has gradually worsened, and three days ago, she had a significant increase in coughing and congestion. Two days ago, she was brought to the emergency department (ED) and was given Xopenex. Mom says they are giving her two puffs every four to six hours, but she doesn’t believe Trish is getting any better. Today, she has increased work of breathing, cough, and gagging with feedings. She began to have post-tussive emesis with feedings earlier today and a fever of 101 degrees, so mom has brought her back in.
REVIEW OF SYSTEMS: As per HPI. All other systems reviewed and are negative.
MEDICATIONS: Other than Xopenex recently given, none. NKDA
FAMILY HISTORY: Mother, father, and brother all have asthma. Father smokes around child in and out of the house.
PHYSICAL EXAM: VSS; patient is fussy. Respiratory rate between 44 and 65, O2 saturation is 100 percent on one-half liter, and 89 percent on room air. Non-toxic child, but notable increased work of breathing.
HEENT: Anterior fontanelle open, soft, and flat. PERRLA. TMs are intact and clear.
CHEST: Symmetrical expansion, + retractions. LUNGS: Diffuse crackles bilaterally, with some wheezing, no rales or rhonchi. CARDIO: RRR, 2/6 vibratory ejection murmur.
ABDOMEN: Soft, non-tender. NABS. SKIN: Normal color, no rashes.
EXTREMITIES: Warm, well-perfused; normal ROM. No clubbing, cyanosis, or edema.
DIAGNOSTIC STUDIES: LABS today: CBC, which shows a white blood cell count of 20.8, hemoglobin of 10.7, hematocrit of 31.3, and a platelet count of 715,000. Differential shows increased neutrophils, 2 bands, and 7% monocytes. UA is negative. CRP is 2.0 mg/L.
CXR: Evidence of bronchial thickening. No significant change since previous X-ray.
ASSESSMENT: Acute bronchiolitis. The patient will be admitted and put on the bronchiolitis pathway, providing her with aggressive suctioning and supplemental oxygen as needed. Due to strong family history of asthma and exposure to smoke, we will monitor the patient closely.
Code the Diagnosis
J21.9 Acute bronchiolitis, unspecified
Z77.22 Contact with and (suspected) exposure to environmental tobacco smoke (acute) (chronic)
Z82.5 Family history of asthma and other chronic lower respiratory diseases
Rationale: The ICD-10-CM codes for acute bronchiolitis identify the causative agent. In this example, the documentation does not state the specific pathogen, such as respiratory syncytial virus; therefore, you would report the unspecified code.
Since the baby is diagnosed with acute bronchiolitis, you would not code the coughing, increased work of breathing, and post-tussive emesis separately. It is important to code the family history of asthma and the exposure to smoke as they relate to the patient’s respiratory issue.