Internal Medicine Coding Alert

Focusing on acute conditions, exacerbations can whip these claims into shape.

Correctly reporting asthma, bronchitis, and chronic obstructive pulmonary disease (COPD) depends on the internists documentation and the patients medical record.

Making sure the documentation supports the patients diagnosis and that you code for any associated acute conditions will ensure that youre correctly reporting pulmonary diagnoses.

Look to 493 for AsthmaWith COPD

One condition that can be associated with asthma is COPD. You can find all of the asthma codes in the 493 category of the ICD-9 codes. When your physician diagnoses both COPD and asthma together, youll refer to his documentation in the medical record to settle on a code. The three asthma codes youll choose from are:

" 493.20 -- Chronic obstructive asthma; unspecified

" 493.21 -- ... with status asthmaticus

" 493.22 -- ... with (acute) exacerbation.

Note: Most payers dont like unspecified codes such as 493.20, so ask your physician whether the patient has status asthmaticus or an acute exacerbation so you can avoid using the unspecified code. If the patient doesnt have either of those manifestations, your only option is to use 493.20.

In black and white: If your physician documents status asthmaticus with any type of COPD, you should report this diagnosis first. Assign the fifth digit of 1 in this case (493.21), not the fifth digit of 2 (493.22), says Cheryl Klarkowski, RHIT, coding specialist with Baycare Health Systems in Green Bay, Wis. Only the fifth digit 1 should be assigned. Status asthmaticus refers to a patients failure to respond to therapy administered during an asthmatic episode and is a life-threatening complication that requires emergency care. 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 asthmaticus).

Use 491.22 for COPD and Bronchitis

Another common condition that patients can have that is associated with COPD is bronchitis. When your physician documents chronic obstructive bronchitis with an episode of acute bronchitis, you should report  491.22 (Obstructive chronic bronchitis; with acute bronchitis), Klarkowski says. You dont 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 combined bronchitis (chronic with acute bronchitis) supersedes the exacer-bation (491.21) or the acute condition alone (466.0), 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 doesnt mention acute bronchitis, you should report 491.21.

Exception: If your physician 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 DxWith Documentation

If youre 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 physician should document the tests he orders, such as x-rays (71010-71035) and pulmonary function tests (PFTs, 94010-94060). Make sure the physician includes enough detail in the medical record to support a diagnosis of COPD before reporting it.