Pulmonology Coding Alert

Be sure you appropriately code exacerbations in asthma and COPD

Your key to correctly reporting chronic obstructive pulmonary disease (COPD) lies in your pulmonologist’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 COPD cases.

When you’re faced with reporting diagnosis codes for COPD, you need to be sure that your coding is accurately identifying the patient’s specific pulmonary condition and any associated acute conditions if necessary. When the patient has other conditions that are related to COPD, those diagnoses are important in determining which ICD9 Codes you should report.

Look to Category 493 For COPD and Asthma

One condition that can be associated with COPD is asthma. You can find all of the asthma codes in the 493 category of ICD-9 codes, says Deborah Grider, CMA, CPC, CPC-H, CPC-P, CCS-P, CCP, EMS, president of Indianapolis-based Medical Professionals Inc. and author of the American Medical Association’s Principles of ICD-9-CM Coding.

When your physician diagnoses both COPD and asthma together, you’ll use the terms he documents in the medical record when you select the code to report. 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 non-specific codes such as 493.20, so if possible check with your pulmonologist to see if the patient has status asthmaticus or an acute exacerbation so that 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 pulmonologist documents status asthmaticus with any type of COPD, you should list that diagnosis first. The status asthmaticus diagnosis “supercedes any type of COPD, including that with acute bronchitis or acute exacerbation,” Grider says. You should only assign the fifth digit of “1” in this case (493.21), not the fifth digit of “2” (493.22).

For COPD and Bronchitis, Use 491.22

Another common condition that patients with COPD have is bronchitis. When your physician documents both COPD and acute bronchitis, you should report 491.22 (Obstructive chronic bronchitis, with acute bronchitis). You don’t have to additionally 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 COPD which is causing an acute exacerbation, for your coding purposes, the bronchitis supercedes the exacerbation, says Alan L. Plummer, MD, professor of medicine in the division of pulmonary, allergy and critical care at the Emory University School of Medicine in Atlanta, Ga. Therefore, you should still report 491.22. If, however, the documentation states that the patient has COPD with acute exacerbation, but doesn’t mention acute bronchitis, report 491.21 (Obstructive chronic bronchitis, with[ acute] exacerbation).

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 should use code 496 (Chronic airway obstruction, not elsewhere classified), advises Grider.

Documentation Must Support COPD Diagnosis

If you’re going to list a COPD diagnosis code, be sure the documentation supports the physician’s diagnosis. For instance, the documentation should include a listing of signs, symptoms and conditions.

Your pulmonologist should also document the tests he orders, such as x-rays (71010-71035), and pulmonary function tests (PFT, such as 94010-94060), and also any therapeutic drug treatment associated with the plan of care for the patient. The tests and treatments help support your physician’s diagnosis of COPD.

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.