Pediatric Coding Alert

" Expanded and refined diagnosis coding for respiratory problems (491-496) presents more choices, and more confusion, for pediatricians. The potentially life-threatening and high-cost condition of asthma (493.xx) is common in pediatrics. So are many types of respiratory infections. Yet the diagnosis can be difficult, especially in young children. Some of these codes have been changed in ICD-9 2002, and pediatricians need to understand the refinements of the asthma diagnosis codes in order to code correctly, and in some cases to justify higher levels of E/M codes.
493.0x for Childhood Asthma
Most pediatric patients with asthma are coded 493.0x; when controlled, the fifth digit will be 0"" and the diagnosis code will be 493.00.
 
ICD 2002 clarifies the fifth-digit asthma classification. The fifth digit ""0"" formerly meant without mention of status asthmaticus; now it also means without mention of acute exacerbation. Use 493.x0 when using an asthma diagnosis code and the child has neither status asthmaticus nor acute exacerbation" says Jeffrey Linzer MD FAAP the AAP representative to the ICD editorial panel. If a child has status asthmaticus code 493.x1; if asthma with acute exacerbation use 493.x2. Omitting the fifth digit will almost certainly result in claim denial.
Bronchiolitis and Reactive Airway Disease
The clinical and coding confusion over diagnosing asthma is complicated for pediatricians in particular. There is gray area between infancy and age 2 or 3 when differentiating between asthma a chronic condition and bronchiolitis (466.1x) an acute condition is difficult. Even a single episode of bronchiolitis in an infant can lead to persistent or recurrent symptoms which are eventually diagnosed as asthma.
 
It's important to know when to use an asthma diagnosis code. Pediatricians establish their guidelines. With infants some pediatricians diagnose bronchiolitis two or three times but by the third or fourth time they call it asthma.
 
Asthma may be overdiagnosed in infants Linzer believes because pediatricians don't check for bronchiolitis and other conditions first. "Asthma is a disease of exclusion in the first year of life which means you need to exclude other diseases allergic rhinitis foreign body gastroesophageal reflux vascular rings and webs bronchiolitis cystic fibrosis bronchopulmonary dysplasia and so on first " he says. "But some physicians will say an infant has asthma without evaluating for an underlying condition."
 
In older children however asthma may be underdiagnosed. An asthma diagnosis may be appropriate but the pediatrician may hesitate to use it due to resistance from the parents. "Some physicians are uncomfortable labeling kids so they use other diagnoses such as bronchitis or reactive airway disease " Linzer says.
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