Pulmonology Coding Alert

Don’t forget to use additional codes to explain the reason for the visit.

Pulmonology coders face a variety of challenges when assigning correct ICD-10-CM codes. Whether it’s your first day or you’re a seasoned coder, some coding rules can be tricky to make sense of.

Read through these three scenarios to learn how important code sequencing principles apply to different situations.

Use Both Guidelines and Patient Documentation

Scenario 1: A patient is diagnosed with bronchopneumonia and influenza A virus. The patient has a history of tobacco dependence and currently lives with a smoker.

In this scenario, there are two distinct diagnoses to code, and instructions on which order to report them in can be found right in the ICD-10-CM code set. When you find J18.0 (Bronchopneumonia, unspecified organism), you’ll notice a Code first alert under the main category that tells you to code the influenza first. The chapter guidelines also list several applicable options in the Use additional code note, which you’ll code second when documentation supports doing so.

“Everything needs to be read together. There is no such thing as remembering everything and knowing what to code without looking at the notes and the guidelines,” advised Sharon J. Oliver, CPC, CDEO, CPMA, CRC, AAPC Approved Instructor, coding consultant and owner of Medical Coding & Consultants in Jonesborough, Tennessee, at the beginning of her AAPC HEALTHCON 2022 presentation “Who’s On First — What’s On Second — I Don’t Know On Third.”

Expert tip 1: To accurately sequence conditions with underlying causes, remember the following: ICD-10-CM Official Guidelines, Section 1.A.13, states “ICD-10-CM has a coding convention that requires the underlying condition be sequenced first, if applicable, followed by the manifestation. Wherever such a combination exists, there is a ‘use additional code’ note at the etiology code, and a ‘code first’ note at the manifestation code.”

Abide by the ‘With’ Guideline

Scenario 2: A physician examines a patient and diagnoses asthma and chronic obstructive bronchitis. The physician has not made a note about whether these conditions are related.

Codes J45.909 (Unspecified asthma, uncomplicated) and J44.9 (Chronic obstructive pulmonary disease, unspecified) are common code choices, but understanding the conditions involved and searching the official guidelines will help you code correctly.

Both asthma and chronic obstructive bronchitis, which is a form of chronic obstructive pulmonary disease (COPD), share similar symptoms and can make breathing difficult. Even though the physician didn’t note if the conditions are related, ICD-10-CM Official Guidelines, Section I.A.15, states “These conditions should be coded as related even in the absence of provider documentation explicitly linking them, unless the documentation clearly states the conditions are unrelated.” In other words, you can use the “With” guideline to code the asthma and chronic obstructive bronchitis together.

When you turn to the ICD-10-CM Alphabetic Index, you’ll find Asthma > with > chronic obstructive bronchitis, which directs you to verify J44.9 in the tabular list. In the tabular list, parent code J44.- (Other chronic obstructive pulmonary disease) features an Includes note that lists “asthma with chronic obstructive pulmonary disease” and “chronic obstructive bronchitis.”

Since chronic obstructive bronchitis is a form of COPD, you can correctly code the asthma and chronic obstructive bronchitis diagnoses with one code.

Clean claim: First code J44.9, then use any additional codes to identify the patient’s exposure to tobacco smoke, tobacco dependence, or tobacco use, if applicable.

Expert tip 2: “There are hundreds of conditions in the ICD-10-CM Alphabetic Index that link conditions using ‘with’ or ‘in.’ This is why it is important to check the index before you make a code selection,” says Kate Tierney, CPC-I, CPMA, CPC, CPC-P, CRC, COGC, CGSC, CEMC, CEDC, CBCS, CMAA, CICS, CHI, CEHRS, CPhT, national coding trainer for Optum RQNS in Highlands Ranch, Colorado. “Highlight the word ‘with’ in the index under the conditions you regularly code,” Tierney suggests.

Don’t Forget Underlying Conditions or Adverse Reactions

Scenario 3: A pediatric patient presents with a painful rash. The provider identified the problem as an allergic reaction to amoxicillin, the antibiotic they were previously prescribed for a bacterial pneumonia infection.

The rash is the reason for the encounter, but the bacterial pneumonia infection is the underlying condition and has not resolved. A bacterial pneumonia infection is coded as J15.9 (Unspecified bacterial pneumonia), and the allergic reaction is a complication of the medication. This means guideline I.C.19.e.5.a comes into play: It tells you “when coding an adverse effect of a drug that has been correctly prescribed and properly administered, assign the appropriate code for the nature of the adverse effect followed by the appropriate code for the adverse effect of the drug (T36-T50).”