ED Coding and Reimbursement Alert

Ensure proper payment with these ICD-9 coding strategies

If you don't need to rely on the patient's signs and symptoms to report the right asthma code, don't - use more specific codes. But keep in mind that in the ED, signs and symptoms may be all the information available.

Medicare focused on asthma for many of its 2004 updates because the disease is a high-profile condition for patients, physicians and payers, says Anthony M. Marinelli, MD, FCCP, chairman of the American Thoracic Society's Clinical Practice Committee. CMS and other carriers may use the data from ICD-9 reports to adjust payments or develop quality guidelines. That's why you should be as accurate as possible when you report diagnosis codes to avoid potential fraud or abuse, he adds.

Watch Your Signs and Symptoms Coding

Having 493.81 (Exercise-induced bronchospasm) and 493.82 (Cough-variant asthma) means that the physician's documentation can medically justify his asthma treatment procedures with more specificity. But it also means that if you are still using signs and symptoms coding, your insurer may deny your claims or the coding practice could trigger an audit, says Mary Mulholland, BSN, RN, CPC, a reimbursement analyst for the office of clinical documentation at the University of Pennsylvania's department of medicine in Philadelphia. 

"When selecting the primary diagnosis code, the coder should first report the ICD-9 diagnosis that most accurately identifies the patient's medical condition," Mulholland says. Coders may also report any additional signs and symptoms, which the physician documents in the medical record, if they contribute to the doctor's services, she adds.

Example: Suppose a child presents to the ED with an acute asthma exacerbation, and also has tachypnea and dehydration. In this case, you would add codes 276.5 (Volume depletion) and 786.06 (Tachypnea).

Don't Forget Bronchitis Descriptors

To ensure that you're accurately coding obstructive chronic bronchitis, you should look for patients' specific levels of exacerbation in the physician's medical documentation, coding experts say. Remember that in 2004, you have revised descriptors for 491.20 (Obstructive chronic bronchitis; without exacerbation) and 491.21 (... with [acute] exacerbation) to help you more specifically determine a patient's level of exacerbation.

Coders should use 491.21 only when the physician specifically identifies that the patient has acute exacerbation, Mulholland says.

Best bet: Remember that 491.20 now represents "without exacerbation," which is a phrase you should look for in the documentation. Previously, the physician had to provide the less specific diagnosis of "without mention of acute exacerbation."

The new descriptors mean the physician must specify that the patient doesn't have exacerbation to justify code 491.20. And if the documentation doesn't support the diagnosis code, your insurer may deny your claim.

Also, be aware that a new code in this series, 491.22 (Obstructive chronic bronchitis with acute bronchitis), is available for use beginning Oct. 1, 2004.