Primary Care Coding Alert

Yellow codes won't cost you $52

You can avoid claim rejections for improper asthma coding if you know how to use 493.xx's revised fifth digit.

Describe Patient's Asthma With Fifth Digit

You should select 493.xx's fifth-digit subclassification based on the patient's current asthmatic state. For the fifth-digit, you may assign:

0 -- unspecified
1 -- with status asthmaticus
2 -- with (acute) exacerbation.

Example: An extrinsic asthma patient presents with wheezing. In this case, you should report 493.02 (Asthma; extrinsic asthma; with [acute] exacerbation), says Maria M. Torres, CPC, CMM, CCC, CMSCS, a consultant who provides services to five family physicians (FPs) through Bermudez Medical Consulting Services in Tampa, Fla. "The '2' signifies that something exacerbated the patient's asthma."

You probably don't have any problems assigning 493.02 when a patient has an asthmatic attack. But you may not know how to code for a controlled asthmatic.

News: ICD-9 2004 changes the code that many FP coders use for controlled asthmatics. Jean S. Oglevee, LPN, CPC, coding compliance coordinator at Family Medicine Clifton/Centreville in Centreville, Va., says that for routine extrinsic asthma visits, she previously reported 493.00. The fifth-digit "0" indicated the patient had "extrinsic asthma, without status or an acute exacerbation or unspecified." "But 493.00 now translates to 'extrinsic asthma, unspecified,' " she says.

Try this: Use 493.00 as you did prior to ICD-9's revision.

Assign '0' for Controlled

Don't let ICD-9 2004's asthma changes throw you. "The revisions are editorial clarifications," says Jeffrey Linzer Sr., MD, MICP, FAAP, ICD-9-CM editorial advisory board representative. The codes still mean the same thing.

For instance, an extrinsic asthma patient presents with a little chest tightness. The 45-year-old-male isn't in distress but needs to renew his Singulair and Advair prescriptions due to the trees blooming.

Action: For the routine, controlled extrinsic asthma visit, you should use 493.00, as you previously did. "Code 493.00 still describes a stable, extrinsic asthmatic," Linzer says.

Snag: Code 493.x0 now appears in ICD-9 as a yellow highlighted code. "As a rule, we don't use unspecified or yellow codes," Oglevee says. The designation usually triggers a denial, which would cut $52 in 99213 (Office or other outpatient visit for the evaluation and management of an established patient ...) revenue from the above controlled asthmatic scenario (fee based on the 2004 Physician Fee Schedule Relative Value File).

But you should sometimes use unspecified codes. In fact in asthma cases, unspecified codes may not even trigger a denial.

Report Unknown Case as .x0

If your FP doesn't mention the patient's asthmatic state, you should report 493.x0. "The '0' indicates that the physician didn't specify that the patient has status asthmaticus or an exacerbation," Torres says. But you never want to use an unspecified code if you have information that the patient is status asthmaticus (fifth digit of 1) or that the patient is having an (acute) exacerbation (fifth digit of 2).

Tactic: If you work in the FP's office, you can look at the patient's record. "The patient's chief complaint will often tell you which fifth digit to use," Torres says. If documentation shows the patient had wheezing -- even if it occurred the night before the patient presented  -- you should use 493.x2, she says.

Reality: Sometimes the FP just notes "asthma." "A family physician often uses this notation for a new patient when he isn't familiar with the patient's symptoms and history," Torres says. In this case, you should assign a fifth digit of 0 to indicate the FP didn't mention whether the patient's asthma is status asthmaticus or exacerbated.

Recoup Unspecified Pay
 
You shouldn't shy away from 493.x0 for fear of nonpayment. "Insurers are paying on the unspecified code," Torres says. Even when Torres files an asthma claim with 493.x0 as the primary and only code, insurers still reimburse the E/M service.

If a payer denies the office visit, you should appeal the decision. In your cover letter, explain that the patient's asthma wasn't exacerbated or status asthmaticus. Therefore, you appropriately reported 493.x0 to indicate that the patient's asthma was controlled or the FP wasn't familiar enough with the patient's history to make a 493.x1 or 493.x2 diagnosis. 

Lesson: You should use a fifth digit of 0 for routine stable asthma follow-ups and unspecified cases without risking E/M pay, such as 99213 for an established patient office visit.