Pediatric Coding Alert

And recognize when RSV is the culprit behind other problems.

Respiratory syncytial virus (RSV) is a respiratory infection that affects the patient’s lungs and airways, and as pediatric coders, you’re probably used to seeing RSV, especially in the winter months. However, since the fall, the number of cases started increasing at an alarming rate around the U.S., according to the Centers for Disease Control and Prevention (CDC).

Learn how to code RSV testing and diagnoses, so you’re ready if cases continue to rise in your practice’s area.

Know How to Code RSV Along With Other Conditions

The CDC reported that approximately 7,175 tests came back positive for the week ending Oct. 8, 2022 (www.cdc.gov/surveillance/nrevss/images/trend_images/RSV14Num_Nat.htm). For that week, there were 2,006 more RSV cases when compared to the same time frame in 2021, and significantly more positive test results than the same time period in 2020. At the same time, the virus began to spread during the summer months, rather than its usual winter peak.

One reason for the explosion in RSV cases may be due to the children’s lack of exposure to different respiratory viruses early in the COVID-19 pandemic because of social distancing and masking. As a result, RSV cases are rising, which is why your providers may be seeing more patients with infections than in the past; and recovery from the illness can be harder for some patients.

“Recovery from RSV is complicated for the very old, the very young, and those with respiratory, cardiac, or immune disorders,” says Sheri Poe Bernard, CPC, CRC, CDEO, CCS-P, of Granite GRC Consulting in Salt Lake City.

The patient’s age is a factor in where an RSV infection sets in. “The lungs or large bronchi are usually the sites of infections in adults. Young children are more commonly infected in the smaller bronchial tubes called bronchioles,” Bernard says.

An RSV infection may also cause other infections to occur. When one infection leads to another, coding of the diagnoses can become complicated. “For bronchitis, bronchiolitis, and pneumonia, the ICD classifies a single code to capture each site and infectious agent for RSV,” Bernard adds.

Bronchitis: You’ll select J20.5 (Acute bronchitis due to respiratory syncytial virus) if the physician documented that the RSV infection is causing an acute case of bronchitis with the patient. Bronchitis occurs when the main airways in the lungs, known as bronchial tubes, become inflamed and cause the patient to cough. Often the bronchial tubes will fill with mucus, which loosens during a coughing bout.

Bronchiolitis: Common in infants and young children, bronchiolitis is inflammation and congestion of the bronchioles (small airways) of the patient’s lungs. A viral infection is the most common cause of bronchiolitis. You’ll assign J21.0 (Acute bronchiolitis due to respiratory syncytial virus) when a physician diagnoses a patient with acute bronchiolitis caused by an RSV infection.

Pneumonia: You’ll assign J12.1 (Respiratory syncytial virus pneumonia) if you have a medical report where the physician has documented that the patient is experiencing pneumonia from RSV. One of the most common viral causes of pneumonia in the U.S. is RSV. Pneumonia is an infection in the lungs, and it is commonly caused by viruses or bacteria.

Recognize RSV As the Cause of Other Diseases

If a medical report arrives on your desk with a confirmed diagnosis of RSV that’s causing another condition in the patient, a single code may not be enough to code the diagnosis. In the ICD-10-CM code set Alphabetic Index, look for Virus, viral > respiratory syncytial (RSV), where you’ll find several conditions related to RSV.

“For generalized respiratory infections, otitis media, or other infection sites, coders are instructed to report two codes: one for the site of infection, and a second code, B97.4 (Respiratory syncytial virus as the cause of diseases classified elsewhere),” Bernard says.

If the physician has documented that the RSV is causing another disease, you’ll start by verifying B97.4 in the Tabular List. Under B97.4, you’ll find a Code first note that instructs you to report conditions related to the RSV, such as a middle ear infection (H65.-, Nonsuppurative otitis media) or an upper respiratory disease (J06.9, Acute upper respiratory infection, unspecified), before reporting B97.4.

Choose the Correct RSV Testing Codes

Mild RSV symptoms are similar to symptoms of the common cold, which means a physician may be able to confirm a diagnosis without additional testing. If the provider suspects an RSV infection because of the patient’s medical history, a physical examination, and the number of cases in the area, the provider may order lab tests to confirm the RSV diagnosis.

A provider may order a blood test to check for an RSV infection. The CPT^® code set includes several codes related to a blood test for RSV, such as:

• 87631 (Infectious agent detection by nucleic acid (DNA or RNA); respiratory virus (eg, adenovirus, influenza virus, coronavirus, metapneumovirus, parainfluenza virus, respiratory syncytial virus, rhinovirus), includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, multiple types or subtypes, 3-5 targets)
• 87632 (… 6-11 targets)
• 87633 (… 12-25 targets)

“Choose the code according to the number of infectious agents being screened,” Bernard says. While 87631-87633 are all used to screen for infectious respiratory viruses, the codes differ in the number of viruses being tested for.

A physician may also capture a mouth or nasopharyngeal (through the nose to the throat) swab to test for an RSV infection. You’ll assign 87807 (Infectious agent antigen detection by immunoassay with direct optical (ie, visual) observation; respiratory syncytial virus) to report a rapid RSV antigen test.

Understand the Severity of an RSV Infection

In the U.S., RSV is the most common cause of bronchiolitis (small airway inflammation) for children younger than 1 year old. According to the CDC, RSV infections result in:

Approximately 58,000 hospitalizations for children under 5 years old

Up to 300 deaths of young children

(Source: www.cdc.gov/rsv/research/us-surveillance.html)

While most adults can recover from the infection in a couple of weeks, the infection affects infants and young children differently due to the pediatric patients’ developing immune system and smaller airways. Like COVID-19 and the flu, RSV spreads through the air; but unlike the previously mentioned viruses, “there is currently no vaccine available to protect against RSV,” Bernard says. However, vaccine research studies are under way and some companies are planning regulatory submissions later this year.