Pulmonology Coding Alert

“More and more payers are paying attention to the correct coding guidelines, not just for CPT^® but for ICD-10 as well. In order to prevent diagnosis denials, it is always best to pay attention to the note changes each year,” says Carol Pohlig, BSN, RN, CPC, manager of coding and education in the department of medicine at the Hospital of the University of Pennsylvania in Philadelphia.

Many of these changes relate to code changes. For example, new code category J4A.- (Chronic lung allograft dysfunction) will have the following notes beneath it:

• Code first, if applicable, heart-lung transplant rejection, lung transplant rejection, other complications of heart-lung transplant, or other complications of lung transplant
• Code also, if applicable, bronchiolitis obliterans syndrome

Pay Attention to New Notes for Old Synonyms

Code J68.4 (Chronic respiratory conditions due to chemicals, gases, fumes and vapors) used to have synonyms listed under the descriptor that meant you would use the code to report the following conditions:

• Emphysema (diffuse) (chronic) due to inhalation of chemicals, gases, fumes and vapors
• Obliterative bronchiolitis (chronic) (subacute) due to inhalation of chemicals, gases, fumes and vapors
• Pulmonary fibrosis (chronic) due to inhalation of chemicals, gases, fumes and vapors

However, on October 1, those synonyms will disappear and be replaced by a Code also, if applicable, note, which tells you code chronic conditions, such as the following:

• Emphysema (J43.-)
• Obliterative bronchiolitis (J44.81)
• Pulmonary fibrosis (J84.10)

Remember That Note Revisions May Be Subtle

Other note updates affect codes that themselves remain unchanged. For example, the Code first note under J84.170 (Interstitial lung disease with progressive fibrotic phenotype in diseases classified elsewhere) will change from “sarcoidosis (D86)” to “sarcoidosis (D86.-).”

Missing these note updates can wreak havoc on your claims’ success. “I’ve seen claims rejected for having two diagnoses that ICD-10-CM identifies as Excludes1 diagnoses. Claims are commonly rejected because a required additional code is missing from the claim,” Pohlig adds.

“Paying close attention to the notes will ensure proper coding and prevent claim denials and rework of those denials,” agrees Penny Walker, CPC, CHONC, CCC, provider coding specialist at the Marshfield Medical Center-Dickinson in Iron Mountain, MI. “Our goal is to code to the most specific diagnosis as possible and following these rules will ensure that.”

For example, if you code for a pulmonologist who diagnosed a patient with chronic obstructive pulmonary disease (COPD) with acute exacerbation and bronchiectasis, but you missed the change in the note under J44.- (Other chronic obstructive pulmonary disease), you may face denials. ICD-10-CM 2024 changes the Excludes1 note to an Excludes2 note, which means you will now be able to report J44.1 (Chronic obstructive pulmonary disease with (acute) exacerbation) with an applicable J47.- (Bronchiectasis) code.

Remember: While they sound similar, Excludes1 and Excludes2 instructions are very different in practice for diagnosis coding.

According to the ICD-10-CM Official Guidelines, section I.A.12.a, Excludes1 is a “pure excludes note,” which means the listed code should never be used at the same time as the code listed above the Excludes1 instruction. Another way of interpreting the rule is that the two conditions cannot occur together.

On the other hand, according to the ICD-10-CM Official Guidelines, section I.A.12.b, an Excludes2 note represents “not included here.” This means that the condition is not a part of the condition represented by the initial diagnosis code, “but a patient may have both conditions at the same time.”

In short, Excludes1 means the two codes may never be used together under most circumstances, while Excludes2 allows two or more codes to be used together, when appropriate. So, changing the note for J44.- changes the diagnosis codes you can report together.