Pulmonology Coding Alert

Hint: ARDS in the newborn should be reported with a different code as in ICD-9.

When your pulmonologist assesses patients for dyspnea, one of the diagnosis that you might come across is acute pulmonary distress syndrome (ARDS) – so it becomes imperative that you know how to report this diagnosis using ICD-10 codes when they come into effect after Oct.1, 2014.

When your pulmonologist makes a diagnosis of acute respiratory distress syndrome (ARDS), you currently turn to 518.82 (Other pulmonary insufficiency not elsewhere classified) as there is no other specific ICD-9 codes to report this condition. Take a look at what you’ll have at your disposal for ARDS when ICD-10’s effective.

Caveats: You cannot report 518.82 if your pulmonologist makes a diagnosis of acute respiratory distress in a newborn. You will have to report a diagnosis of acute respiratory distress in a newborn with 769 (Respiratory distress syndrome in newborn). You also cannot report 518.82 if the respiratory distress occurs in an adult patient after any trauma or a surgical procedure. You will report this with the ICD-9 code 518.52 (Other pulmonary insufficiency, not elsewhere classified, following trauma and surgery) that includes respiratory distress following trauma or surgery.

When ICD-10 codes come into effect, 518.82 in ICD-9 crosswalks to J80 (Acute respiratory distress syndrome). You’ll use the same diagnosis code if the acute respiratory distress is diagnosed in an adult or a child. You will use this ICD-10 code even if your pulmonologist mentions the diagnosis as adult hyaline membrane disease.

Watch out: As in ICD-9, you cannot use J80 to report a diagnosis of acute respiratory distress syndrome if the condition is diagnosed in a newborn child. In such a case, you will have to use P22.0 (Respiratory distress syndrome of newborn) to report this diagnosis. The same code holds good if your pulmonologist makes a diagnosis of hyaline membrane disease in a new born child.

Pay Heed to These Basics Briefly

Documentation spotlight: When your pulmonologist arrives at a diagnosis of acute respiratory distress syndrome, some of the signs and symptoms that you are more likely to find in the patient documentation will include dyspnea upon exertion, anxiety, tachypnea, and agitation.

Upon examination, your pulmonologist might note tachycardia, tachypnea, cyanosis in the nails and the presence of cold extremities. Upon auscultation, your pulmonologist might note the presence of rales bilaterally.

If your pulmonologist suspects a diagnosis of acute respiratory distress syndrome, he will try to assess the inciting cause (such as sepsis, acute pancreatitis, drug overdose, aspiration, etc) for the condition. He will also try to differentiate the condition from other conditions such as cardiogenic pulmonary edema.

If your pulmonologist suspects acute respiratory distress syndrome, he will withdraw an arterial blood sample and send it to the laboratory to check for arterial blood gases to record arterial oxygen tension (PaO₂) and arterial carbon dioxide tension (PaCO₂). Some of the other lab tests that will be performed will include a complete blood count, white blood cell count, BNP levels, liver function tests and kidney function tests that will help diagnose the condition and to recognize any complications arising from the condition.

Apart from this, your pulmonologist will order for a chest x-ray to check for lung infiltrates, CT scan, and echocardiography. Your pulmonologist will also perform a bronchoscopy to check for infection and hemorrhage. During the bronchoscopy, your pulmonologist will undertake a bronchoalveolar lavage and suction out the fluid that will be sent in for analysis.

Based on history, signs and symptoms, physical findings, lab findings, findings from x-ray and CT and observations from bronchoscopy, your pulmonologist will arrive at a diagnosis of acute respiratory distress syndrome.

Example: Your pulmonologist reviews a 63-year-old male patient for complaints of severe dyspnea and agitation. Your pulmonologist performs a comprehensive history and then proceeds to examine the patient. During examination, the patient appears to be in a state of anxiety. Your pulmonologist notes presence of cyanosis and tachycardia. Upon auscultation, he notes the presence of fine bilateral rales.

Your pulmonologist withdraws an arterial blood sample and sends it to the lab for analysis of blood gases.He also orders for a chest x-ray and echocardiography. He also asks for CBC, kidney and liver function tests. “Until the diagnosis of acute respiratory distress syndrome is confirmed, the physician will use the signs or symptoms (e.g., R23.0: cyanosis, or R00.0: tachycardia, unspecified) to order the testing” says Carol Pohlig, BSN, RN, CPC, ACS, senior coding and education specialist at the University of Pennsylvania, Department of Medicine in Philadelphia.

The results of blood gas analysis return with a PaO₂ value of 40 mm Hg and chest x-ray shows bilateral infiltrates. The results of other tests show no abnormalities in liver or kidneys.

Your pulmonologist performs a bronchoscopy during which he performs a lavage by instilling saline and suctioning it. Your pulmonologist sent the suctioned fluid to the lab for analysis that returned results positive for increased eosinophil counts.

Based on the history, signs and symptoms, physical examination, results from tests and bronchoscopy, your pulmonologist arrives at a diagnosis of acute respiratory distress syndrome.

What to report: You report the evaluation of the patient with 99223 (Initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components…). You will report the lavage that your pulmonologist performed using 31624 (Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with bronchial alveolar lavage). You will report the diagnosis of acute respiratory distress syndrome using J80 if you are using ICD-10 codes or 518.82 if you are using ICD-9 codes.