Pediatric Coding Alert

Expanded and refined diagnosis coding for respiratory problems (491-496) presents more choices, and more confusion, for pediatricians. The potentially life-threatening and high-cost condition of asthma (493.xx) is common in pediatrics. So are many types of respiratory infections. Yet the diagnosis can be difficult, especially in young children. Some of these codes have been changed in ICD-9 2002, and pediatricians need to understand the refinements of the asthma diagnosis codes in order to code correctly, and in some cases to justify higher levels of E/M codes.

493.0x for Childhood Asthma

Most pediatric patients with asthma are coded 493.0x; when controlled, the fifth digit will be 0"" and the diagnosis code will be 493.00.
 
ICD 2002 clarifies the fifth-digit asthma classification. The fifth digit ""0"" formerly meant without mention of status asthmaticus; now it also means without mention of acute exacerbation. Use 493.x0 when using an asthma diagnosis code and the child has neither status asthmaticus nor acute exacerbation" says Jeffrey Linzer MD FAAP the AAP representative to the ICD editorial panel. If a child has status asthmaticus code 493.x1; if asthma with acute exacerbation use 493.x2. Omitting the fifth digit will almost certainly result in claim denial.

Bronchiolitis and Reactive Airway Disease

The clinical and coding confusion over diagnosing asthma is complicated for pediatricians in particular. There is gray area between infancy and age 2 or 3 when differentiating between asthma a chronic condition and bronchiolitis (466.1x) an acute condition is difficult. Even a single episode of bronchiolitis in an infant can lead to persistent or recurrent symptoms which are eventually diagnosed as asthma.
 
It's important to know when to use an asthma diagnosis code. Pediatricians establish their guidelines. With infants some pediatricians diagnose bronchiolitis two or three times but by the third or fourth time they call it asthma.
 
Asthma may be overdiagnosed in infants Linzer believes because pediatricians don't check for bronchiolitis and other conditions first. "Asthma is a disease of exclusion in the first year of life which means you need to exclude other diseases allergic rhinitis foreign body gastroesophageal reflux vascular rings and webs bronchiolitis cystic fibrosis bronchopulmonary dysplasia and so on first " he says. "But some physicians will say an infant has asthma without evaluating for an underlying condition."
 
In older children however asthma may be underdiagnosed. An asthma diagnosis may be appropriate but the pediatrician may hesitate to use it due to resistance from the parents. "Some physicians are uncomfortable labeling kids so they use other diagnoses such as bronchitis or reactive airway disease " Linzer says.
 
Reactive airway disease reflects a number of possible diseases Linzer says. There is no diagnosis code for it. Typically you should code RAD as wheezing (786.07). Check with the physician who used "RAD" in chart notes and ask "Do you mean asthma or wheezing?"

Unspecified Codes

The unspecified code 493.9x (asthma unspecified) can be useful for babies under 1 year old.
 
"I use unspecified asthma especially on the infants and it is paid " says Maria Vivat biller with Virginia Allergy and Pediatrics. "But sometimes the insurance company sends it back and asks for more information." For this reason before filing a claim with 493.90 Vivat checks with the pediatrician to make sure that is the correct diagnosis.
 
Do not use an asthma code unless the child has asthma. A child who has recurrent wheezing every winter may have asthma or bronchitis. Do not use even the nonspecific 493.9x for bronchitis that is associated with a respiratory infection Linzer says. For this child code acute bronchitis (466.0) in the primary position and an upper respiratory infection (URI) (465.9) in the secondary position. If a child has a URI but also has asthma and is wheezing code asthma with exacerbation (493.02) in the primary position and the URI in the secondary position.

Coding Symptoms

"If the patient is really having difficulty breathing and also has a cold or a cough we would always code the asthma diagnosis in the primary position " Vivat says. "On the other hand if the patient has chronic asthma but is not tight and instead has a cough or a fever we would code that symptom (cough 786.2) first and the asthma second." Again Vivat requests that her physicians tell her which diagnosis is primary. "The doctor is the one who knows the best diagnosis " she says. "Check with his notes and if they don't give the answer ask the pediatrician." If you use two diagnoses you may be able to bill a higher-level office visit.

Controlled Asthma

If a child with asthma that is controlled comes in for a well visit don't list the asthma diagnosis code at all Linzer says. Use only V20.2 (routine infant or child health check). "Outpatient coding rules say you code for the reason for the encounter " he says. If the child is on steroids however you may be justified in billing an E/M code in addition to the well visit. In that case code the well visit and the office visit with modifier -25 (significant separately identifiable E/M service by the same physician on the same day of the procedure or other service) with the appropriate diagnosis code.
 
Many of the refinements are aimed at distinguishing between chronic conditions which asthma is by definition and acute conditions such as bronchitis. The reason is to track more accurately management of chronic conditions.

Diagnostic and Coding Guidelines Conflict

There has been discussion about adding diagnosis codes to better reflect asthma diagnosis guidelines from the National Institutes of Health (the National Heart Lung and Blood Institute). The guidelines categorize asthma severity as mild intermittent mild persistent moderate persistent and severe persistent. The clinician determines the category based on how frequently one has symptoms and on measurements of lung function and that determines how aggressive the treatment needs to be. However these categories do not convert to ICD-9 coding guidelines.
 
ICD-9 coding originates with the World Health Organization (WHO) which uses it for tracking diseases. Terms such as "extrinsic" (493.0) and "intrinsic" (493.1) come from the WHO but have little to do with terms that are used in medical practice. Nevertheless in this country where ICD-9 coding is used for reimbursement the accepted diagnosis code for childhood asthma is 493.0x.