Pulmonology Coding Alert

Focus on acute conditions and precedence rules to select the right code

Your correct interpretation of the pulmonologist’s documentation and the patient’s medical record is the key when reporting lung diagnoses such as asthma, bronchitis and chronic obstructive pulmonary disease (COPD). To seal the deal, just make sure the documentation supports the physician’s diagnosis and that you code for any associated acute conditions.

Follow these simple rules to recoup the max out of your diagnosis coding.

Step 1: J44 and J45 Code Combos Clear the Way to COPD- Associated Asthma

One condition that can be associated with asthma is COPD. There is a lot of change in the way you report asthma with COPD in ICD-10. Now, you will find all of the asthma codes in the J45.- (Asthma) family of ICD-10 codes, whereas the COPD related codes are now recognized as J44.- (Other chronic obstructive pulmonary disease). When your physician diagnoses both COPD and asthma together, you’ll use the terms she documents in the medical record to finally settle on a code or a combination of codes. Effectively, you’ll need to report two codes for this patient.

For reporting COPD-associated asthma, you will first list J44.1 (Chronic obstructive pulmonary disease with [acute] exacerbation) and then follow with a J45.- code to describe the type of asthma your patient has, as directed by the instructional note found at the J44.- category to code also the type of asthma if applicable.

New: The classification for asthma in ICD-10 is reflective of current terminology used in the field: intermittent versus persistent. Under the persistent category, you’ll find three levels: mild, moderate and severe persistent. The classification is criteria based and uses the age and components of severity (impairment and risk).

Impairment includes frequency of symptoms, number of nighttime awakenings, short-acting beta2-agonist use for symptom control, and interference of symptoms with normal activity.

Note: Most payers don’t like nonspecific codes such as J44.9 (Chronic obstructive pulmonary disease, unspecified), so if possible check with your pulmonologist to see if the patient has intermittent or persistent asthma so you can avoid using the unspecified code. If the patient doesn’t have those conditions, your only option is to use J44.9.

If your pulmonologist documents status asthmaticus with any type of COPD, you should list that diagnosis first. You can report the condition (subject to other parameters of persistence etc.) with code J45.52 (Severe persistent asthma with status asthmaticus).

Watch this: If status asthmaticus is documented by the provider with any type of COPD or with acute bronchitis, the status asthmaticus should be sequenced first. It supersedes any type of COPD including that with acute exacerbation or acute bronchitis. Do not code asthma with an acute exacerbation (J45.51, Severe persistent asthma with [acute] exacerbation) together with status asthmaticus. Only one of them should be assigned.

Step 2: For COPD and Bronchitis, Use J44 and J20

Another common condition that patients can have that is associated with COPD is bronchitis. When your physician documents both chronic obstructive bronchitis and an episode of acute bronchitis, you have more codes to report than before. You should sequence J44.0 (Chronic obstructive pulmonary disease with acute lower respiratory infection) first. You’ll need to add an additional code to identify the infection, if known. This is due to the instruction for J44.0 to “Use additional code to identify the infection.” In this case, that code comes from the J20.- (Acute bronchitis) category, and if the type of acute bronchitis is not further specified, the code is J20.9 (Acute bronchitis, unspecified). Finally, you should report J44.1.This sequencing note means you can’t list the acute bronchitis first. At category J20.-, you’ll see an Excludes 2 note that excludes acute bronchitis with chronic obstructive pulmonary disease (J44.0). An Excludes 2 note means the condition is “Not included here.” So, the condition excluded is not part of the condition represented by the code, but a patient may have both conditions at the same time and it’s OK to code for both. Since this patient has both conditions, it’s appropriate to add this code.

Finally, you want to list the acute exacerbation with J44.1. Even though there is an “excludes note” for J44.0 at this code, it is another Excludes 2. Since both conditions are present, you should code for them both. Listing these codes covers the fact that the patient has COPD with an acute lower respiratory infection, specifies the type of infection, and indicates that the COPD is in exacerbation.

Precedence: 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.

Exception: If your pulmonologist diagnoses COPD and there are no other manifestations or conditions such as chronic bronchitis or emphysema that are associated with COPD, you can always resort to J44.9.

Step 3: 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. 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 pulmonologist should document the tests she orders, such as x-rays (71010-71035) and pulmonary function tests (PFT, such as 94010-94060). Make sure that 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. Taking a full past medical history, identifying family history and social history, are also important steps when your physician performs an E/M service on a patient with COPD.