Internal Medicine Coding Alert

Ask these three questions to keep your documentation clear and precise.

Your practice has probably seen plenty of patients with respiratory conditions, so you know how hard they can be to code. Your internist might not be able to offer precise diagnoses right away, as many of the conditions feature variables that don't match up with specific codes. And when you add in the variables of location and severity, your coding choices can be pretty complex.

So, don't let the confusion get the better of you. Instead, ask these three questions and add a breath of fresh air to your documentation.

Ask, "Am I coding the symptoms or the diagnosis?"

Initial encounters with patients suffering from respiratory distress often don't conclude with an authoritative diagnosis, which means you will often end up bypassing the J00-J99 (Diseases of the Respiratory System) codes in favor of choosing a sign or symptom from the R00-R09 (Symptoms and signs involving the circulatory and respiratory systems) code block.

But be careful when you do, as some symptom and sign codes that look like respiratory conditions may not be so. For example, Chelle Johnson, CPMA, CPC, CPCO, CPPM, CEMC, AAPC Fellow billing/credentialing/auditing/coding coordinator at County of Stanislaus Health Services Agency in Modesto, California, points out "You would only use R07.0 (Pain in throat) if the pain could not be identified as a disease relating to the respiratory system." Otherwise, you would use a more specific diagnosis, such as J31.2 (Chronic pharyngitis) or J02.9 (Acute pharyngitis, unspecified).

Similarly, Johnson maintains, you would only use R06.2 (Wheezing) "if any of the respiratory system disease codes such as J44- (Other chronic obstructive pulmonary disease), J45- (Asthma), or any of the J40-42 bronchitis codes are not warranted."

Ask, "Is this condition unidentified or unspecified?"

Plenty of the diseases and infections listed in the J00-J99 group feature the word "unspecified" as part of their descriptors. But this does not mean they are unknown, and it does not mean that a condition has yet to be identified.

The Official Guidelines for ICD-10-CM define "unspecified" codes as being "for use when the information in the medical record is insufficient to assign a more specific code." Or, as Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians defines them, "Unspecified codes are usually definitive diagnoses where the typology is unspecified. If the physician knows the patient has a particular condition but does not provide enough specifics to choose a more well-defined code for that condition, the coder would use an unspecified code."

So, when your provider is waiting on information from a test, for example, or has made a preliminary diagnosis but needs the further expertise of a specialist, such codes should be used until greater specificity is possible. If the physician has not yet identified what condition the patient has, then you should fall back to reporting the signs and symptoms that prompted the encounter.

Ask, "Is this condition in one site or multiple sites?"

Many of the J00-J99 codes are indexed to specific anatomical sites. So, several code blocks specify upper (e.g. J00-J06 (Acute upper respiratory infections) and J30-J39 (Other diseases of respiratory tract)) or lower (e.g. J20-J22 (Other acute lower respiratory infections) and J40-J47 Chronic lower respiratory diseases)) sites, making it easier for coders to pinpoint the precise section of the respiratory system where the disease or infection is located.

However, ICD-10-CM guidelines explicitly state that "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." Or, as Moore explains, "if there is not a single code that covers a respiratory condition that occurs in both the upper and lower parts of respiratory system, one should report the code that covers the lower anatomic site."

The ICD-10-CM note offers one example of this: tracheobronchitis. This disease affects both the trachea in the upper part of the respiratory system as well as the bronchi, which are a part of the lower respiratory system. Because of that, you would code it as J40 (Bronchitis, not specified as acute or chronic) - the lower of the two anatomical sites.

The same is also true for bronchopneumonia. As Johnson notes, even though bronchopneumonia is specific to causing inflammation in the bronchi, it is considered as part of the pneumonia diagnosis for J12- (Viral pneumonia, not elsewhere classified), J13 (Pneumonia due to Streptococcus pneumoniae), J14 (Pneumonia due to Hemophilus influenzae), or J15- (Bacterial pneumonia, not elsewhere classified).

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