Internal Medicine Coding Alert

Focus on acute conditions and exacerbations to select the right code

Your key to correctly reporting asthma, bronchitis and chronic obstructive pulmonary disease (COPD) lies in the internist's documentation and the patient's medical record. 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 Category 493 for Asthma Associated With COPD

One condition that can be associated with asthma is COPD. You can find all of the asthma codes in the 493 category of ICD-9 codes. When your physician diagnoses both COPD and asthma together, you'll use the terms he documents in the medical record to finally settle on a code. 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 internist 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 your internist 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, Wisc.

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."

For COPD and Bronchitis, Use 491.22

Another common condition that patients can have that is associated with COPD is bronchitis. When your physician documents both 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 since 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-CM 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 make any mention of acute bronchitis, you should report 491.21

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

Support COPD Diagnosis With Documentation

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 www.pcsbilling.com 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."

Your internist should document the tests he orders, such as x-rays (71010-71035) and pulmonary function tests (PFT, such as 94010-94060). Make sure that you have enough detail in the history of present illness and the review of systems to support a diagnosis of COPD before reporting a COPD code.

Taking a full past medical history, identifying family history and social history, are also important steps when your physician performs an E/M service on a patient
with COPD.

For more information on documentation for COPD, see our article "Look for Keywords to Support COPD" on page 3.