Pulmonology Coding Alert

Hint: Watch out for signs of acute exacerbation and respiratory infections.

As bronchiectasis is one type of chronic obstructive pulmonary disease -- and a frequently-reported diagnosis, you'll need to be cued in on how to report the condition using ICD-10 codes when the use of this code set kicks off on Oct. 1, 2014.

Look for Signs of Exacerbation in ICD-9

When reporting a diagnosis of bronchiectasis, you will have to use the ICD-9 code 494 (Bronchiectasis). The inclusions for this code are a diagnosis of recurrent bronchiectasis as well as bronchiolectasis. However, you cannot use this code to report congenital bronchiectasis (748.61) and tuberculous bronchiectasis (011.5).

Depending on the presence or absence of symptoms of acute exacerbation, 494 in ICD-9 further expands to the following two codes:

• 494.0 -- Bronchiectasis without acute exacerbation
• 494.1 -- Bronchiectasis with acute exacerbation

Identify Etiology With Additional Code in ICD-10

A diagnosis of bronchiectasis you report with 494 in ICD-9 crosswalks to J47 (Bronchiectasis) when you begin using ICD-10 code sets. The list of exclusions remains the same as it is in ICD-9. The exclusions for this code contain congenital bronchiectasis (Q33.4) and tuberculous bronchiectasis (A15.0).

However, you will have to use an additional code to identify the etiology such as an exposure to environmental tobacco smoke (Z77.22); history of tobacco use (Z87.891); tobacco dependence (F17.-);tobacco use (Z72.0); occupational exposure to environmental tobacco smoke (Z57.31) and exposure to tobacco smoke in the perinatal period (P96.81).

J47 has three expansions into the following codes depending on the presence of other symptoms or symptoms of acute exacerbation:

• J47.0 (Bronchiectasis with acute lower respiratory infection)
• J47.1 (Bronchiectasis with [acute] exacerbation)
• J47.9 (Bronchiectasis, uncomplicated)

"This may make the attention to detail in documentation more important than before. Providers will need to understand the difference between each of the codes in order to ensure proper code selection," says Carol Pohlig, BSN, RN, CPC, ACS, senior coding and education specialist at the University of Pennsylvania, Department of Medicine in Philadelphia.

Focus on Specifics in Documentation

Symptoms that you will commonly see with a diagnosis of bronchiectasis will include chronic cough (R05, Cough) and sputum production (R09.3, Abnormal sputum). There may be the presence of hemoptysis (R04.2, Hemoptysis) or the sputum might be just green in color. Some of the other symptoms that might be present include chest pain (R07.1, Chest pain on breathing); shortness of breath (R06.00, Dyspnea, unspecified); wheezing (R06.2, Wheezing); fever (R50.9, Fever, unspecified) and weight loss (R63.4, Abnormal weight loss).

Upon examination of the patient, your pulmonologist might record crackles or rhonchi in the documentation. You might also see wheezing upon auscultation. Your pulmonologist might also note the presence of cyanosis, digital clubbing and signs of heart failure.

Your pulmonologist will order for a chest x-ray or a CT scan if he suspects a diagnosis of bronchiectasis based on the symptoms and findings on examination. He might also order for blood tests and sputum analysis to aid the diagnosis. He will also perform pulmonary function tests (PFT) to check for the extent of the progress of the condition.

Example: Your pulmonologist assesses a patient suffering from symptoms of chronic cough with copious amounts of mucopurulent sputum production with occasional hemoptysis. The patient also complains of increasing incidents of dyspnea and pleuritic chest pain. The symptoms had seen a sudden spurt in the past few weeks and he has been experiencing signs of fever along with the other symptoms.

Your pulmonologist performs a detailed history recording and then proceeds to perform a detailed examination of the patient and notes respiratory crackles along with presence of cyanosis and clubbing in the digits. You report the evaluation of the patient with 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components...).

He orders a chest x-ray and sputum analysis. He also orders for a complete blood count. He then performs pulmonary function tests and notes decline in forced expiratory volume in 1 second (FEV_1). You report this test with 94010 (Spirometry, including graphic record, total and timed vital capacity, expiratory flow rate measurement[s], with or without maximal voluntary ventilation). Based on all the findings, your pulmonologist arrives at a diagnosis of bronchiectasis. You report the diagnosis with 494.0 if you are using ICD-9 and J47.9 if you are using ICD-10 set of codes.