Pulmonology Coding Alert

Hint: Causative organism is still the basis for selecting the code as in ICD-9.

When your pulmonologist assesses patients for shortness of breath, he’ll be looking for causes, such as acute bronchiolitis especially in young infants and children. Be clear about how to code this diagnosis when you begin using ICD-10 codes beginning Oct.1, 2014.

Settle for Two Coding Options in ICD-9

When your pulmonologist makes a diagnosis of acute bronchiolitis, you have only two choices if you’re using the ICD-9 code sets. Based on the causative organisms, you have to use the following two code choices for acute bronchiolitis:

466.11 — Acute bronchiolitis due to respiratory synctial virus [RSV]

466.19 — Acute bronchiolitis due to other infectious organisms

Note: The inclusions list specifies that you use the same diagnosis codes for acute bronciolitis with bronchospasm and excludes respiratory bronchiolitis interstitial lung disease that has to be reported using 516.34 (Respiratory bronchiolitis interstitial lung disease). If the bronchiolitis is caused to other infectious organisms, you need to report the causative organism with an additional code to identify it. But, be sure to use only confirmed causative organisms, and not suspected causes.

Observe Broader Reporting Options in ICD-10

When you begin using ICD-10 codes, 466 (Acute bronchitis and bronchiolitis) in ICD-9 will crosswalk to J21 (Acute bronchiolitis) in ICD-10. However, your coding options, even though dependent on the causative organism as in ICD-9, will be enhanced as more choices are available in the ICD-10 coding system."Acute bronchitis expands into 10 J20 codes, depending upon the causative organism, when known," adds Carol Pohlig, BSN, RN, CPC, ACS, senior coding and education specialist at the University of Pennsylvania, Department of Medicine in Philadelphia.

So, a diagnosis of acute bronchiolitis can be reported using ICD-10 codes using the following four coding options:

J21.0 — Acute bronchiolitis due to respiratory syncytial virus

J21.1 — Acute bronchiolitis due to human metapneumovirus

J21.8 — Acute bronchiolitis due to other specified organisms

J21.9 — Acute bronchiolitis, unspecified

Reminder: As you can see from the descriptors to the above mentioned codes, you have two separate codes to report acute bronchiolitis caused due to respiratory syncytial virus and human metapneumovirus. If the acute bronchiolitis is caused from any other identified organism, you have to settle for J21.8. "When you are coding for physician services, be sure to use the code related to the causative organism only from the date that it was identified," says Pohlig. "Prior to confirmation (if not confirmed on the same date as the initial visit), report the unspecified code." If your pulmonologist arrives at the diagnosis of acute bronchiolitis without mentioning the causative organism, you can go for the unspecified code.

Focus on These Basics Briefly

Your pulmonologist will arrive at the diagnosis of acute bronchiolitis preliminarily based on age of the patient, history, seasonal occurrence, symptoms and findings of a physical examination. When your pulmonologist makes a diagnosis of acute bronchiolitis, you will usually find symptoms such as shortness of breath (R06.00, Dyspnea, unspecified); tachypnea (R06.82, Tachypnea, not elsewhere classified); wheezing (R06.2, Wheezing); cough (R05, Cough), congestion (R09.81, Nasal congestion), fever (R50.9, Fever, unspecified) and difficulties in feeding or eating (R13.10, Dysphagia, unspecified) in the documentation of the patient. Upon physical examination, your pulmonologist might note tachypnea, tachycardia, wheezing or rales upon auscultation and presence of hypoxia.

Since diagnosis is principally made upon age, symptoms and physical examination, tests are usually done to rule out other diagnoses or to check for the causative organism. Your pulmonologist might order for a rapid test for RSV and perform other tests such as WBC count, arterial blood gases, C-reactive protein and order for a chest x-ray. He might also perform a pulse oximetry to assess the severity of the condition.

Example: Your pulmonologist is called in to assess an 8-month-old infant admitted in the hospital for being very irritable, fussy and having feeding problems. The infant’s mother also communicates to your pulmonologist that the child is experiencing breathing difficulties and makes wheezing sounds during breathing.

Your pulmonologist performs a thorough recording of the patient’s history and then proceeds to perform a thorough examination of the patient. He observes elevated temperature, tachypnea and tachycardia in the documentation and notes fine wheezing sounds heard on auscultation.

Based on the age of the patient, symptoms experienced and due to the occurrence of episodes of acute bronchiolitis in the particular season, your pulmonologist arrives at a preliminary diagnosis of acute bronchiolitis.

He performs a pulse oximetry and sends blood samples to the lab to test for RSV, WBC, ABG and C-reactive protein. The lab tests for RSV return positive. Based on the test results, your pulmonologist confirms a diagnosis of acute bronchiolitis due to respiratory syncytial virus.

How to code:You report the evaluation of the patient with 99222 (Initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components…), 94760 (Noninvasive ear or pulse oximetry for oxygen saturation single determination) for the pulse oximetry and J21.0 if you are using ICD-10 codes or 466.11 if you are using ICD-9.