EM Coding Alert

Specialty Spotlight:

Discover How to Capture Severity in These Pediatric Pulmonology Scenarios

Published on Fri Sep 24, 2021

Hint: You may need to append a modifier.

Exercise-induced bronchospasm (EB) and exercise-induced asthma cases may be popping into your office now that school has started and fall sports are in full swing. Keep your coding skills sharp with this expert advice.

Start Your Coding With an ICD-10-CM Code

Exercise-induced asthma is a condition where the airways in the lungs narrow when triggered by strenuous exercise. The patient may suffer from wheezing, coughing, shortness of breath, and other symptoms during or after exercising (URL: http://my.clevelandclinic.org/health/diseases/4174-exercise-induced-asthma).

You will use code J45.990 (Exercise induced bronchospasm) to report the diagnosis, but you may be wondering: should you also report the severity of the asthma with J45.2- (Mild intermittent asthma)? The answer is no, “not unless they actually have that type of asthma. Typically, if they have exercise-induced asthma, they don’t have a definitive asthma like mild intermittent asthma,” says Donelle Holle, RN, Pediatric Coding Consultant, President of Peds Coding, Inc. in Fort Wayne, Indiana.

Note: “While there are indeed codes identified for each of these categories, there is no specific guidance indicating to either use or exclude reporting additional codes from the J45 series,” says Donna Walaszek, CCS-P, Medical Billing, Credential and Coding Specialist, Northampton Area Pediatrics in Northampton, Massachusetts.

Understanding the visit, diagnosis, and treatment of exercise-induced asthma can be tricky, even for the most experienced of coders. The following scenario will help refresh your exercise-induced asthma coding skills.

Code the Confirmation of EIB

Scenario: A pediatric patient is referred to a pulmonologist and presents symptoms of coughing, wheezing, shortness of breath, and fatigue during exercise. The patient lives in a smoke-free home and is not a user of tobacco. Though the symptoms appear primarily when the patient has been exercising or playing hard with friends, the pulmonologist may require further testing to confirm the diagnosis.

After the initial visit, the pulmonologist would order pulmonary function tests (PFTs) to help assist in their diagnosis. These PFTs allow the physician to test the functionality of the patient’s lungs and what exacerbates the symptoms.

Depending on the ordered procedures, you will use any of the following codes to document the visit:

94010 (Spirometry, including graphic record, total and timed vital capacity, expiratory flow rate measurement(s), with or without maximal voluntary ventilation);
94060 (Bronchodilation responsiveness, spirometry as in 94010, pre- and post-bronchodilator administration) with ECG recordings;
94617 (Exercise test for bronchospasm, including pre- and post-spirometry and pulse oximetry; with electrocardiographic recording(s));
94619 (Exercise test for bronchospasm, including pre- and post-spirometry and pulse oximetry; without electrocardiographic recording(s));
94618 (Pulmonary stress testing (eg, 6-minute walk test), including measurement of heart rate, oximetry, and oxygen titration, when performed);
And other tests in 94610-94690 codes that fall under Pulmonary Diagnostic Testing and Therapies.

Definition: A spirometry test measures the functionality of the patient’s lungs when they’re not exercising. The pulmonologist may have the patient take an inhaled medication to open the lungs, and then repeat the test to compare the results of the two tests. An exercise test helps the physician assess the patient’s symptoms while exercising. Performing spirometry tests before and after the exercise challenge can show evidence of EIB.

Code the Provider’s Treatment Plan

The doctor has diagnosed the patient as suffering from exercise-induced bronchospasm, but what’s next? “The [physician] and family will decide if medication is right for the patient,” says Walaszek.

Holle says, “Typically [the physician] would put them on a controller medication to be used when exercising, as well as possibly using [an] inhaler for pre-exercise if they are going to be doing heavy exercise or for quick relief.”

During the visit, if the doctor is prescribing a treatment and teaching the patient and parents how to use the nebulizer or inhaler, you will use codes 94640 (Pressurized or nonpressurized inhalation treatment for acute airway obstruction for therapeutic purposes and/or for diagnostic purposes such as sputum induction with an aerosol generator, nebulizer, metered dose inhaler or intermittent positive pressure breathing (IPPB) device) or 94664 (Demonstration and/ or evaluation of patient utilization of an aerosol generator, nebulizer, metered dose inhaler or IPPB device).

Important: If you are coding 94640 and 94664 on the report, they must be performed separately during the visit. Double-check the documentation to see if the instructions are given involving a medication or mode different than the one used for treatment — in that case, 94664 will not be counted as a separate teaching component.

Remember: If the pulmonologist performs both procedures and they are distinct from one another (e.g., the physician provides a nebulizer treatment in the office, and teaches the patient about using an inhaler with a spacer), then code 94664 will require modifier 59 (Distinct procedural service) to override the bundling edit in National Correct Coding Initiative (NCCI). Make sure your pulmonologist has supporting documentation.

Plus, when coding the E/M visit with 99202-99205 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using time for code selection, …), you will need to append modifier 25 (Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service).