Pulmonology Coding Alert

Clinical signs of moderate and mild asthma to drive your choice of codes.

You report COPD and asthma all the time, but are you sure you’re correctly identifying asthma type and the specific cause for a patient’s COPD from the provider’s notes? Refresh your COPD and asthma coding acumen with these examples.

Case 1: A past smoker complaining of breathlessness and cough presents to the pulmonologist. He says that his father also had a similar problem. The provider orders a chest CT and identifies the patient’s condition as Panacinar emphysema, associated with antitrypsin deficiency. Which codes would you report?

Answer: You would report J43.1 (Panlobular emphysema) along with an additional code Z87.891 (Personal history of nicotine dependence) to indicate his past history of smoking.

Case 2: A chronic smoker with tracheobronchitis who is on albuterol is seen in the physician’s office. How would you code this condition?

Answer: Although this is a case of tracheobronchitis, the provider does not mention any further specifics.

If the tracheobronchitis was due to Bordetella bronchiseptica, you would code A37.80 (Whooping cough due to other Bordetella species without pneumonia), or A21.8 (Other forms of tularemia) if the causative organism was Francisella tularensi. This code selection may be appropriate, based on the causative organism, says Carol Pohlig, BSN, RN, CPC, ACS,  senior coding and education specialist at the Hospital of the University of Pennsylvania.

However, as there is no such documentation here, according to the CMS guidelines, “when a respiratory condition is described as occurring in more than one site and is not specifically indexed, it should be classified to the lower anatomic site.” So, you would report bronchitis code J40 (Bronchitis, not specified as acute or chronic) instead of tracheobronchitis.

Case 3: A 40-year-old male with known asthma for 10 years, on inhaled corticosteroids, visits your physician. The patient has been taking short-acting beta agonists, and complains of an increase in breathlessness for the past few days. How do you report this scenario?

Answer: This is a known case of asthma, and the patient is on medications. However, there has been an acute exacerbation recently, as the patient complains of increase in breathlessness. The most appropriate code here would be J45.31 (Mild persistent asthma w [acute] exacerbation).

“Be sure that your physician has identified the asthma classification in the documentation so that you won’t be tempted to select this in your own,” cautions Pohlig.

Pohlig adds that mild persistent asthma is a condition with presence of any one of the following, without treatment:

• Symptoms do not occur on a daily basis, but at least two days in a week
• Patient may feel breathless in night three to four times a month
• Normal lung function in absence of asthma attack

Case 4: A 50-year-old known asthma patient needs inhaled corticosteroids on a regular basis to control her breathlessness and symptoms. Her lung function values are 60 percent of the expected, and she has difficulty carrying out her activities of daily living.

Answer: This patient needs inhaled corticosteroids to manage her symptoms on a regular basis. As the symptoms affect her daily activities, and also her lung function values show a dip, the symptoms show mild persistent asthma. There seems to be no evidence of a sudden onset or increase in existing symptoms, so you do not need to think on the lines of an acute exacerbation. So the right code here would be J45.40 (Moderate persistent asthma, uncomplicated).

Pohlig describes moderate persistent asthma as having the following characteristics:

• Patient is on daily medications as symptoms occur daily
• Patient may feel breathless in night more than once a week.
• Abnormal lung function — 60 to 80 percent of normal

Final takeaway: “Be careful not to assign a diagnosis that the patient does not have or specify a condition that has not been specified by the physician,” says Pohlig. “If you suspect that the patient has a given condition, such as mild persistent asthma, based on the physician documentation of symptoms, ask the physician to clarify and specify the dx in order to avoid assumption coding.”