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Pulmonology Coding Alert

Asthma Codes Affected by ICD-9 Changes for 2002

Published on Thu Nov 01, 2001

Pulmonologists diagnosing asthma will find 10 changes in the 2002 edition of the ICD-9 manual, including two new codes, one minor revision and two additions. Asthma by ICD-9 definition is the "transient narrowing of airway diameters in the bronchial tree, restricting airflow, and causing labored breathing and wheezing."
 
Although the changes are not radical, they are significant because they give physicians the option of labeling a patient's condition as "unspecified." This generalized condition is noted by the description for the "zero" in the fifth-digit subclassification of the asthma subcategory 493 that states "without mention of status asthmaticus or acute exacerbation or unspecified." In 2001, the "zero" in the fifth-digit subclassification included only the description of "without mention of status asthmaticus."
 
For example, when a patient presents with a condition that is diagnosed as extrinsic asthma, physicians can now use the diagnosis code 493.01 if the medical condition is status asthmaticus, 493.02 if it is acute exacerbation, and 493.00 for an unspecified condition.

Unspecified May Be Too Nebulous
 
Although the "unspecified" option of labeling a patient's condition may give physicians more latitude in terms of a generalized diagnosis, some medical professionals fear it may compromise accuracy.
 
"We don't like to use unspecified codes," says Kristine Heth, CPC, University of South Carolina Medical School in Charleston, S.C.  "When the physician's diagnosis just says 'asthma,' you want to know why the patient has been coming to the doctor, and are they having problems. It is important to have an accurate code to put on our claim for reimbursement.  What we would like to see is a more specific diagnosis to determine the proper fifth digit or code. For example, is the patient being admitted to the hospital for acute exacerbation, status asthmaticus or uncontrolled asthma?"
 
Heth says coders need to know the severity of the condition or reason for the admission other than an unspecified diagnosis for asthma to ensure higher reimbursement and more exact records. The unspecified code should be used only as a last resort.

Other Code Changes and Modifications
 
Physicians reporting a patient's diagnosis as extrinsic asthma or  "a transient stricture of airway diameters of bronchi due to environmental factors also called allergic (bronchial) asthma" can report 493.0x. Code 493.1x can be reported for intrinsic or late-onset asthma caused by pathophysiological disturbances, and 493.2x can be used for chronic obstructive asthma or asthma with chronic obstructive pulmonary disease (COPD). Code 493.9x can now be used for asthma unspecified, without mention of status asthmaticus or acute exacerbation or unspecified.
 
Chronic obstructive asthma with acute exacerbation is excluded from a patient who presents obstructive chronic bronchitis in 491.21. Code 466.0 for acute bronchitis has a subset that excludes acute bronchitis with bronchiectasis (494.1) and COPD (491.21)
 
Two new codes have been added: 464.50 (unspecified supraglottitis, without mention of obstruction) and 464.51 (unspecified supraglottitis, with obstruction.)
 
A fifth digit has been added to 464.00 and 464.01 for acute laryngitis to identify the absence or presence of an obstruction.

Archaic Language Is Still a Hurdle
 
Compliance with using the term COPD will be an obstacle that pulmonology coders will continue to face, as this term is generally not used by American physicians. This has been an ongoing problem since the diagnostic codes were first written. The only way to combat and avoid a claim denial is to ensure a physician uses the most exact definition possible to describe the condition. Coders will always be faced with having to deal with the verbiage a physician uses when diagnosing a medical condition even if it doesn't fit within common coding nomenclature. Being educated and alert to coding regulations and changes, along with knowing what the physician is saying in his or her interpretation, are valuable skills for a coder to hone.
 
"The problem with all the obstructive lung disease ICD-9 codes is that many of them are not words we use in critical care and pulmonary medicine," says Charlie Strange, MD, FCCP, department of pulmonary medicine, Medical University of South Carolina. "For instance, no one uses chronic obstructive asthma, 493.2x, although a hospital gets higher levels of reimbursement compared to intrinsic or extrinsic asthma. There is no discussion in any of our textbooks for obstructive lung disease, nor does it show itself in any of the pages of our journal articles.
 
"The problem with this is the international part of ICD-9," Strange says. "When these codes were first constructed, the Europeans described a different set of words for a short-wheezing patient. When the ICD-9 codes were first developed they tried to put these patients in separate diagnoses rather than subsets."
 
Strange also issued a caveat about physicians using such a generalized diagnosis as "unspecified asthma" in 493.9x, stating that more specific terminology when billing will result in higher reimbursement. The reimbursement does not vary based on selected ICD-9 codes, but the claim risks denial if the insurers do not consider the code "medically necessary."

The Importance of Keeping Up-to-Date
 
Medical experts say pulmonary practices would further benefit from an annual review and update of encounter forms or superbills used in their offices. These yearly "refreshers" will assist in two ways, according to Mary Mulholland, RN, CPC, reimbursement analyst with the Hospital of the University of Pennsylvania, department of medicine in Philadelphia
 
"Review will allow the practice to make sure that the ranges of diagnosis codes printed on their forms are correct," Mulholland says. "It also allows the physicians and practice managers to be aware of any codes that require updating, as well as the ability to remove diagnosis codes that are rarely used."
 
Mulholland says updating the forms helps the practice to free up space on the encounter form and permits the addition of codes that must be handwritten.
  
Medicare mandates ICD-9 codes for physicians when billing for services rendered to Medicare beneficiaries. Many private insurance carriers also use the system. The most recent ICD-9 code changes went into effect Oct. 1, 2001, and will be mandatory for billing by Jan. 1, 2002.

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