ICD 10 Coding Alert

Remember to contact the provider when you need clarification.

You know how important diagnosis coding is to your overall reimbursement strategy, and you know that diagnosis coding is a huge component of confirming any particular procedure’s medical necessity.

These scenarios involve pulmonology situations, but make sure you’re relying on these best practices when choosing ICD-10 codes for any specialty.

Don’t Guess — Contact Providers When Necessary

Suppose the physician’s dictation specifically states that the patient has lobar pneumonia, but then the documentation refers to treating bilateral pneumonia, leaving the coder to wonder whether the lobar or bilateral code applies. What should you do?

Solution: “Show the discrepancy in the documentation to the physician; once the answer is clarified, the physician should amend the chart note with the appropriate information,” says Elizabeth Cifers, MBA, MSW, CHC, CPC, of Elizabeth Cifers Consulting LLC. “If the physician uses a scribe, educating both the physician and scribe is essential,” she adds.

If the chart documentation does not provide the highest level of specificity to assign a diagnosis code correctly, show the provider the options in the ICD-10-CM code book, so they can see the dilemma in selecting the correct code, she suggests. “Many physicians have been documenting the same way since residency and fellowship and do not realize the level of specificity that ICD-10-CM requires. Education concerning the problem is key to correcting and preventing future occurrences.”

Important: Don’t be afraid to speak up when there is a question or discrepancy in the documentation, Cifers advises. “Unless someone informs the physician, he or she may not know there is an issue.”

Aim for Confirmed Diagnoses

A patient presents with shortness of breath, wheezing, and cough. The pulmonologist suspects chronic obstructive pulmonary disease (COPD) and orders radiological tests to get a closer look at the patient’s lungs. The physician circles COPD on the superbill, but when the tests come back, the doctor does not confirm that diagnosis. What should you do?

Solution: In this case, you should only report the signs and symptoms as they appear in the medical record, which in this case include R06.02 (Shortness of breath), R06.2 (Wheezing), and/or R05 (Cough). This is the best route, since you should never report suspected diagnoses.

But if COPD is the definitive diagnosis and stipulated by the provider in the medical record, coding for this situation would require a code from the J44 (Other chronic obstructive pulmonary disease) code category. That means starting your search with J44.9 (Chronic obstructive pulmonary disease, unspecified) although that may not be the only code you might use.

When seeking signs and symptoms to report, “remember first to locate the term in the Alphabetical Index, then use the Tabular list to verify the code selection, the laterality, and, if applicable, the seventh character code,” Cifers notes.

Understand Common Acronyms

The physician sees a patient who presented with shortness of breath and a cough. For the final diagnosis, the pulmonologist writes “PAP” in the medical record. This term is unfamiliar to the coding team, so what should you do?

Solution: In this case, it sounds like the physician has diagnosed the patient with pulmonary alveolar proteinosis, often notated by physicians as “PAP.” These patients find it difficult to take oxygen from the air and exchange carbon dioxide from the blood due to a buildup of proteins and lipids in the patients’ air sacs. When patients present with this condition, they’ll often complain of shortness of breath (R06.02), dyspnea (R06.00), or a cough (R05). You should code these symptoms only if the physician hasn’t yet diagnosed the patient with PAP.

Once the patient is diagnosed with PAP, you’ll report J84.01 (Alveolar proteinosis) for both primary and secondary presentations. However, in cases of secondary alveolar proteinosis, you’ll also report the cause, such as a lung infection or inhalations of dust such as aluminum, using the appropriate ICD-10 codes.

Note that this suggests there may possibly be a larger issue in the practice, which is the fact that the pulmonologist is using acronyms that may be unfamiliar to the coding staff. You should get to know the most common acronyms that your clinicians use and keep a running list of them. And when in doubt, always consult the providers.