Otolaryngology Coding Alert

Extrinsic means "coming from or originating from the outside," says Pamela Kulczar, CPC, CCP, medical office coordinator for the University of Texas Health Center at Tyler South Tyler Clinic in Tyler, Texas.

In extrinsic asthma, an outside source, such as grass or pollen, causes the asthma. "Symptoms can include allergic rhinitis (477.x), atopic dermatitis (691.8), as well as asthma (493.xx)."

"Intrinsic asthma is situated entirely within or pertaining exclusively to a part," Kulczar says, citing Stedman's Medical Dictionary. "Something within the patient causes the asthma." The patient does not usually exhibit the same signs and symptoms of extrinsic asthma, such as rhinitis and dermatitis, but he may have similar asthma symptoms, she explains.

Chronic obstructive asthma is for patients who have chronic obstructive pulmonary disease (COPD, 496). COPD is a general term for a temporary or permanent narrowing of the small bronchi. Pulmonologists, rather than otolaryngol-ogists, tend to treat COPD patients.

Unspecified asthma describes the diagnosis when no further diagnosis is available. Whenever possible, you should avoid the generalized diagnosis for a more specific one, which will result in higher reimbursement and fewer denials.

2. Use a Fifth Digit to Describe the Asthma's Status

To identify the asthma's current state during the patient's visit, assign the appropriate fifth-digit subclassification:

For patients who do not have status asthmaticus or acute exacerbation, use the 0. Code 493.x0 is appropriate when the patient presents for a checkup and his or her asthma is controlled.

The 1 indicates that the patient has status asthmaticus, which is a medical emergency and usually treated in the emergency department.

Assign a 2 for patients who present with asthma that is currently exacerbated. This means something made the patient's asthma worse.

ICD-9 instructs coders to "assign fifth-digit subclassification codes for those categories where they are available." "The fourth and fifth digits are important because they paint a more complete picture of the patient's condition at the time of the encounter," Kulczar says.

Without a complete picture, the payer may deny the claim for lack of medical necessity. "Coders should be coding to the most specific code versus using the generic code," especially when a nebulizer is involved, says Chrissy Letsen, CPC, billing coordinator with Metropolitan ENT in Alexandria, Va.

For instance, an asthma patient experiences an acute exacerbation that requires a nebulizer treatment (94640, Pressurized or nonpressurized inhalation treatment for acute airway obstruction or for sputum induction for diagnostic purposes [e.g., with an aerosol generator, nebulizer, metered dose inhaler or intermittent positive pressure breathing (IPPB) device]). In this case, you should link 94640 to 493.x2. Reporting 493.x2 will help the payer understand why the patient needs the treatment, Letsen says. Assigning 493.x0 will incorrectly inform the carrier that the patient's asthma is under control, making a treatment unnecessary.

Compare this example to coding for a stable patient. A patient comes in for a follow-up visit following an initial visit to treat exacerbated asthma. The otolaryngologist concludes that the patient's asthma is well controlled. Assign the appropriate office visit code (99211-99215, Established patient office visit) linked to 493.x0. The asthma is under control and absent of status asthmaticus or acute exacerbation.

Of course, each of these examples requires the appropriate fourth-digit code, which requires determining the asthma's source. Environmental factors, rather than internal causes, usually trigger asthma. So, you will probably assign extrinsic asthma more often than intrinsic.

4. Minus Definitive Diagnosis,You Report Symptoms

When a patient presents with an undiagnosed respiratory problem, the otolaryngologist must often run diagnostic tests to determine the problem's source. Reporting an asthma diagnosis before the physician finalizes the condition can inappropriately label a patient as an asthmatic. Absent a definitive diagnosis, you should report the patient's signs and symptoms.

For instance, a patient complains of frequent shortness of breath and wheezing. The otolaryngologist examines the patient, concentrating on the lungs, upper airways, eyes, ears, nose (particularly the nasal passages) and throat. The physician cannot evaluate the caliber of the airways from that information alone. So, he does not enter a definitive diagnosis. You should report the symptoms, shortness of breath (786.05) and wheezing (786.07).

5.List the Main Diagnosis First

When a patient presents with another problem, such as an earache, in addition to asthma, diagnosis coding depends on the symptoms' severity. Report the chief complaint first, Kulczar says. This will help the payer understand the medical necessity of the procedures and services provided. If asthma is the main reason for the examination, a primary asthma diagnosis will show the payer why certain procedures, such as an inhalation treatment, are necessary. In addition, it will help support a higher-level E/M because of the increased level of risk and medical decision-making involved in treating an acute exacerbation. If the patient is stable but asthma is the underlying cause, a supporting asthma diagnosis explains why the patient may require a more extensive examination than a patient who does not have a chronic illness.

For instance, a child who has extrinsic asthma presents with difficulty breathing and also has an ear infection. Because the patient now has asthma symptoms, report the asthma diagnosis (493.02) in the primary position and the otitis media diagnosis (382.9) second. If the patient has chronic asthma, however, but is not tight and instead has an ear infection, report otitis media first and the controlled asthma (493.00) as an underlying cause.

Or, an intrinsic asthma patient who is allergic to his own bacteria presents with a fever (780.6) and cough (786.2). The patient's history shows that he often experiences acute exacerbations when he is sick. The otolaryngologist diagnoses an upper respiratory infection (URI). He spends a lot of time examining the patient's respiratory infections and making sure that his asthma is controlled. Report the diagnosis for a URI (465.9) first and the intrinsic asthma diagnosis (493.10) second. This shows the payer that the patient's asthma is under control but plays a significant role in the current office visit.