Pulmonology Coding Alert

Pinpoint originating cause and exacerbating factors to avoid rejections.

You may as well say goodbye to your well-earned reimbursement if you haven’t been as diligent in documenting the reporting of pulmonary diseases such as chronic obstructive pulmonary disease (COPD), obstructive bronchitis, acute bronchitis, asthma and emphysema. Have you made sure that the documentation completely matches up with the patient’s diagnosis and any accompanying conditions have been factored in into your final submission document? Pause and ask yourself these three questions before making a final report.

1. Bronchitis: Acute or Obstructive?

When a patient presents with acute airway obstruction, the condition is many times accompanied with chronic obstructive bronchitis. Therefore, if your physician confirms a case of chronic obstructive bronchitis with an episode of acute bronchitis, you should not have much difficulty in reporting 491.22 (Obstructive chronic bronchitis with acute bronchitis). A selection of 466.0 (Acute bronchitis) will be wrong here as 491.22 perfectly captures the dual nature of the symptoms.

However, if the physician notes down a case of chronic obstructive bronchitis with acute exacerbation without any noting a cause of acute bronchitis, you should report 491.21 (Obstructive chronic bronchitis with [acute] exacerbation). If the chronic obstructive bronchitis is categorized as emphysema without exacerbation and acute bronchitis, you should use code 491.20 (Obstructive chronic bronchitis without exacerbation).

Note: According to ICD-9-CM Guidelines, if there is presence of dual bronchitis (chronic + acute) that is causing an acute exacerbation, coding the combined bronchitis will take precedence over exacerbation (491.21) and a standalone acute condition (466.0). Therefore, 491.22 is your best bet for acute bronchitis with chronic obstructive bronchitis.

Caution: If your physician’s primary diagnosis is generalized COPD and he has not recorded any other symptomatic conditions pointing to chronic bronchitis or emphysema, you should use 496 (Chronic airway obstruction, not elsewhere classified).

2. Is a COPD Diagnosis Confirmed?

Check whether you have confirmatory evidence in your documentation that points to a foolproof diagnosis of COPD because amajority of lung ailments present themselves via common signs: shortness of breath and cough. These symptoms neither confirm any disease nor point you in the right direction. Therefore, make sure your documentation contains all relevant clinical tests and work-ups ordered by the physician and his interpretations with confirmation before reporting it as COPD. You should note down the various factors influencing the diagnosis such as a detailed history (any tobacco use ongoing or previous). Your physician should document the tests he orders, such as X-rays (71010-71035) and pulmonary function tests (PFTs, 94010-94060). Make sure the physician includes enough detail in the medical record to support confirmation of the COPD diagnosis, particularly noting the pulmonary function tests 94010 (Spirometry, including graphic record, total and timed vital capacity, expiratory flow rate measurement[s], with or without maximal voluntary ventilation) or 94060 (Bronchodilation responsiveness, spirometry as in 94010, pre- and post-bronchodilator administration).

Caution: At the time of billing, the physician will record only the signs or symptoms that prompted him to order the test. You should wait for the final reports to code the final diagnosis and not report possible diagnoses. Airflow limitation documented by pulmonary function testing must be present before you can confirm COPD in a patient with a smoking history.

3. Does “Airflow limitation” Indicate Asthma? 

When a patient presents with airflow limitation, it may be a sign of asthma, because chronic asthmatics or patients with long-duration asthma often display such symptoms. The 493 category contains all the ICD-9 asthma codes. Use 493.2x for asthma with airflow limitation. After confirmation through clinical testing you should pick from the following three asthma codes:

• 493.20 -- Chronic obstructive asthma unspecified
• 493.21 --... with status asthmaticus
• 493.22 --... with (acute) exacerbation.

Note: COPD can manifest together with asthma. After your physician has diagnosed both COPD and asthma together, you should pick from the above codes after referring the documentation. Thus, you would use these three codes for asthma with airflow limitation or for asthma with the nonspecific diagnosis of COPD. When reporting 493.2x, follow these guidelines: 

“Status asthmaticus” with airflow limitation with or without COPD takes precedence in coding and you should code it as primary diagnosis if the physician has documented it in his medical record. This condition is a life threatening complication as the patient fails to respond to therapy administered during an asthmatic episode and requires emergency care, thereby superseding any type of COPD, including that with acute exacerbation (493.22) or acute bronchitis.The fifth digit expansion will change to “1”(493.21), instead of “2” (493.22) in such a scenario. 

Go slow: You should use unspecified codes, such as 493.20, very sparingly as payers may reject it on the grounds that ICD-9 contains a more specific code. Don’t try to use this code as “one size fits all” diagnosis solution by confirming with your physician whether the patient has status asthmaticus or an acute exacerbation. Use the 493.20 code only as a last resort when you have exhausted all other possibilities of pinpointing the diagnosis.