Primary Care 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 your physician'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 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 physician 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 physician 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, Wis.

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 a.4. of the ICD-9-CM Guidelines, which you can find online at www.cdc.gov/nchs/datawh/ftpserv/ftpicd9/icdguide06.pdf. -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. 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. However, if the documentation states that the patient has chronic obstructive bronchitis with acute exacerbation but doesn't mention acute bronchitis, report 491.21 (Obstructive chronic bronchitis; with [acute] exacerbation).

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 code 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 physician should document the tests he orders, such as x-rays (71010-71035) and pulmonary function tests (PFT, such as 94010 or 94060). Make sure 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.

Look for Keywords to Support COPD

Physicians will base an initial COPD diagnosis on several factors, and the best documentation will include extensive information about each factor. Edde offers the following tips that most COPD documentation will include:

In the HISTORY: Should include whether or not the patient had a history of cigarette smoking. The vast majority of COPD patients have a history of smoking cigarettes. The remaining patients have a history of exposure to pollutants, dusts and chemicals, evidence of genetic tendency (such as alpha-1 Antitrypsin) or history of chronically and poorly controlled asthma.

In the SYMPTOMS: Shortness of breath (also known as dyspnea) and cough are the cardinal symptoms. Excessive sputum production, wheezing, recurrent upper respiratory tract infections (URI) are commonly present.

In the RADIOGRAPHICAL workup: The chest x-ray shows hyperinflation with flattening of the diaphragms. The CT of the chest is more sensitive and can correlate more accurately with the severity of COPD, so documentation should include details about these tests results.

In the PHYSIOLOGICAL workup: Pulmonary function testing (PFT) is the confirmatory test. You cannot make a solid diagnosis of COPD without having PFT in the medical record. Flow-rate limitation on spirometry and air trapping on the lung volumes are the hallmark findings. Reduced diffusion lung capacity for carbon monoxide (DLCO) is in favor of emphysema, while normal DLCO is in favor of chronic bronchitis.

In the BLOOD WORK, there are no specific failure: In emphysema, hypoxemia is more pronounced, while in chronic bronchitis, hypercapnea (CO2 retention) is more evident. 

Chronic hypoxemia can result in erythrocytosis (elevated hemoglobin and hematocrit) on the complete blood count (CBC), while CO2 retention will lead to elevation of serum bicarbonate (HCO3-) on the electrolytes. Your physician should include all of these readings in his documentation when he first diagnoses the patient with COPD.