Pulmonology Coding Alert

After an ICD-9 code is reported on an insurance claim, it enters into the system as a lifetime record for that patient. Coding for tuberculosis (TB) is an excellent example of how this can be a serious problem. Insurers can penalize patients for a pre-existing condition they may not have or know theyve been labeled as having until they change insurance carriers and find it listed as a pre-existing condition.

A positive tuberculosis screening doesnt mean that the person has TB, so dont use a TB code, says Carol Pohlig, BSN, RN, CPC, of the University of Pennsylvania department of medicine in Philadelphia. Unless they are clinicians, most coders and billers do not understand the terminology used for TB codes. They may look for a word-for-word representation in the medical record that is not going to be there because the doctor does not know how it is stated in the ICD-9 book.

Dont label a patient with a positive tuberculosis screen by using the ICD-9 code for TB, Pohlig says. Instead, use the appropriate PPD (positive purified protein derivative of tuberculin) ICD-9 code. If you code it as TB, their insurance company has a record that says the person has TB and is now a liability. In other words, while a positive skin test may be from a TB infection, it may not mean they have TB. The appropriate positive ICD-9 code for this is 795.5 (nonspecific reaction to tuberculin skin test without active tuberculosis).

Coding a Definite TB Diagnosis

Coding a patient who tests positive for TB beyond a simple screening can be tricky. Using the fifth digit appropriately can be a big problem. Pohlig points out that coders cant just open the ICD-9 book and read the code because the physician isnt going to write in his notes identified positively through positive culture. He might write positive and then name the test, she says. To be able to use the fifth digit appropriately and to code to the highest level of accuracy the coder needs to be familiar with the methods of TB testing.

Scott Manaker, MD, interim vice chair of clinical affairs and director of clinical documentation at the department of medicine at the University of Pennsylvania in Philadelphia, says that the first step in accurately coding a TB patient is figuring out which organ the disease has invaded. He observes that the ICD-9 book has nine sets of TB codes from 010 through 018. If its extra-pulmonary, match it up to the appropriate code for the organ system, Manaker says. Look up the affected organ for extra-pulmonary TB. Whether it is TB of bones and joints (015), genital-urinary system (renal TB) (016), miliary TB (018) or something else, it has a code.

Manaker says that if the TB is pulmonary, different types are specified in the 011 category. Whether its TB pneumonia (011.6), TB bronchiectasis (011.5) or TB fibrosis (011.4), if its an infiltrate or nodule, all these things should be in the physicians notes.

That Important Fifth Digit

For each of the different anatomic codes you need that fifth digit, depending on how the TB was diagnosed. If the physician does say how it was diagnosed, coders should look at the list in the ICD-9 book that shows the fifth-digit codes for TB. Manaker points out that if a physician reports TB of the lung without clarifying how the diagnosis was made, the coder needs to find out and use the correct fifth digit.

TB can be diagnosed by culture, DNA probes, or even histologic specimen, Manaker says. If the fifth digit is two (011.x2) that means the physician has done the test but doesnt know the results yet. That would be a patient who has been diagnosed with TB in one site, but the specimen from a different body site is still pending, according to Manaker. After 011.x2, the codes become much clearer. This is where the majority of the coding would occur, certainly in the pulmonary coding primer, he says.

Finding the following terms in the physicians notes may lead coders to the appropriate fifth digit. The fifth digit for 011.x3 refers to TB found in sputum by microscopy and may be noted as a positive smear discovered by using a stain such as Ziehl-Neilson stain, Rhodamine Flourescence stain or Carbol-Fuchsin stain. The fifth digit for 011.x4 is for TB found by culture. This means that the patients initial smear was negative, but TB grew out in the culture within the six-week period for which cultures are held. Fifth-digit 011.x5 is for TB found by histology, meaning a biopsy specimen. Manaker says, A point of confusion is what to do with a lymph node that is aspirated, and the smear of the aspirate shows TB. I would say thats going to be fifth-digit 011.x3; it was found by microscopy but not in a sputum specimen. Fifth-digit 011.x6: TB found not by bacteriology or histology but by other methods. Thats how I would code DNA probes, Manaker says. You could make the argument that you only do a DNA probe if you already have a positive culture, so you could also be OK coding it with the fourth digit.