ED Coding and Reimbursement Alert

Status asthmaticus diagnosis trumps any COPD the patient may have

When a patient presents to the ED with asthma or bronchitis along with symptoms of chronic obstructive pulmonary disease (COPD), you-ll need to check the physician's notes in order to choose the correct diagnosis code from the ICD-9 manual.

Making sure the documentation supports the physician's diagnosis--and that you code for any associated acute conditions--will ensure that you-re correctly reporting lung diagnoses.

Look to 493 for Asthma Associated With COPD

When choosing a diagnosis code for a patient with asthma and COPD, you-ll need to go to the 493.x section of ICD-9. Suppose the ED physician diagnoses both COPD and asthma together; the three asthma codes you-ll choose from are:

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

Note: Most payers don't like nonspecific codes such as 493.20, so if possible check with your physician to see if the patient has status asthmaticus or an acute exacerbation, so you can avoid using the unspecified code. If the patient doesn't have those conditions, your only option is to use 493.20.

If the physician documents status asthmaticus with any type of COPD, you should list that diagnosis first. You should only assign the fifth digit of -1- in this case (493.21, Obstructive chronic asthma; with status asthmaticus), not the fifth digit of -2- (493.22), says Cheryl Klarkowski, RHIT, coding specialist with Baycare Health Systems in Green Bay, Wis.

In black and white: -If status asthmaticus is documented by the provider with any type of COPD or with acute bronchitis, the status asthmaticus should be sequenced first,- according to chapter 8, section 1C of the ICD-9-CM Guidelines. -It supersedes any type of COPD including that with acute exacerbation or acute bronchitis. It is inappropriate to assign an asthma code with fifth-digit -2,- with acute exacerbation, together with an asthma code with fifth-digit -1,- with status asthmatics. Only the fifth-digit -1- should be assigned.-

COPD With Bronchitis Calls for 491.22

When your physician documents chronic obstructive bronchitis with an episode of acute bronchitis, you should report 491.22 (Obstructive chronic bronchitis; with acute bronchitis), Klarkowski says. You don't have to report 466.0 (Acute bronchitis) for the obstructive chronic bronchitis because the code descriptor for 491.22 specifies acute bronchitis.

Tip: If your physician documents that a patient has acute bronchitis with chronic obstructive bronchitis that is causing an acute exacerbation, the bronchitis supersedes the exacerbation for your coding purposes, according to the ICD-9 Guidelines.

Therefore, you should still report 491.22. But if the documentation states that the patient has chronic obstructive bronchitis with acute exacerbation but doesn't mention acute bronchitis, you should report 491.21(Obstructive chronic bronchitis; with [acute] exacerbation).

Exception: If the physician diagnoses COPD and there are no other associated manifestations or conditions such as chronic bronchitis or emphysema, you should use 496 (Chronic airway obstruction, not elsewhere classified).

Heavy History Documentation Good Practice for COPD Coding

If you-re going to list a COPD diagnosis code, be sure the documentation includes a listing of signs, symptoms and conditions.
 
-Unfortunately, almost all the diseases of the lungs manifest themselves in a very similar fashion: shortness of breath and cough,- says Pierre Edde, MD, founder of PCS Billing in Uniontown, Pa. -By themselves, they are not specific for any disease entity. Therefore, clinical evaluation, based on a detailed history, is of prime importance. Once clinically suspected, blood studies, along with radiographical and physiological evaluations, will complement the workup in order to make a diagnosis,- Edde says.

Your physician should document the tests he orders, such as x-rays (71010-71035) and pulmonary function tests (PFT, such as 94010-94060). Taking a full past medical history, identifying family history and social history, is also an important step when your physician performs an E/M service on a patient with COPD.

(Note: For more information on documentation for COPD, see the next article, -Keywords Can Guide You to Correct COPD Diagnosis.-)