Pulmonology Coding Alert

Hint: Pulmonary infiltrates NOS should be reported with a different code as in ICD-9.

When your pulmonologist diagnoses pulmonary eosinophilia, you’ll have to check out whether the causative factor is extrinsic or intrinsic as ICD-10 codes have specific diagnosis codes based on the etiology unlike what is currently followed using ICD-9 coding system.

ICD-9: When your pulmonologist makes a diagnosis of pulmonary eosinophilia, you’ll report this with 518.3 (Pulmonary eosinophilia) when you are using the ICD-9 set of codes. You’ll use the same diagnosis code when your pulmonologist mentions the diagnosis as eosinophilic asthma, Loffler’s syndrome, tropical eosinophilia or allergic and eosinophilic pneumonia. If your pulmonologist makes a diagnosis of pulmonary infiltrates NOS, you cannot report it with 518.3. You will instead report it with 793.19.

Observe Enhancements to Exclusion Lists in ICD-10

When ICD-10 system of codes comes into effect, the ICD-9 code 518.3, used to report a diagnosis of pulmonary eosinophilia caused due to intrinsic or idiopathic factors, crosswalks to J82 (Pulmonary eosinophilia, not elsewhere classified). The list of inclusions is similar to the ICD-9 coding system and you will report the same diagnosis code if your pulmonologist makes a diagnosis of eosinophilic asthma, Loffler’s syndrome, tropical eosinophilia or allergic and eosinophilic pneumonia.

However, the list of exclusions is vaster and comprises in addition to pulmonary infiltrates NOS (R91.8), other manifestations of pulmonary eosinophilia caused by infections or other extrinsic factors such as pulmonary eosinophilia due to aspergillosis (B44.-), pulmonary eosinophilia due to drugs (J70.2-J70.4), pulmonary eosinophilia due to specified parasitic infection (B50-B83), and pulmonary eosinophilia due to systemic connective tissue disorders (M30-M36).

Pay Heed to These Basics Briefly

Documentation spotlight: When your pulmonologist arrives at a diagnosis of pulmonary eosinophilia, some of the signs and symptoms that you are more likely to find in the patient documentation will include dyspnea, fever, wheezing, chest pain, night sweating, cough, weight loss and hemoptysis.

Upon examination, your pulmonologist might note skin rash, rhinitis, sinusitis, jugular venous distension (JVD), and peripheral edema. Upon auscultation, your pulmonologist might note the presence of rales and wheezing.

If your pulmonologist suspects a diagnosis of pulmonary eosinophilia, he will try to assess the inciting cause (such as parasitic, fungal or bacterial infections, medications, drugs, other systemic conditions, or due to idiopathic reasons) for the condition.

If the suspected diagnosis is pulmonary eosinophilia, your pulmonologist will obtain a stool sample to check for parasitic causes. He will also order for other lab tests such as CBC, WBC differential count, and immunoglobulin levels. This will help your pulmonologist assess the causative factor for the eosinophilia and also help in ruling out extrinsic factors to be the cause if the eosinophilia is idiopathic.

Testing: Your pulmonologist will also order for chest x-rays to help distinguish the type of eosinophilia and may also ask for a CT scan of the chest for the same reason. Apart from this, your pulmonologist might ask for other tests such as pulmonary function testing, perfusion scanning, and skin tests to obtain a differential diagnosis.

Your pulmonologist might also perform a bronchoscopic alveolar lavage (BAL) to help in confirming a diagnosis of pulmonary eosinophilia and to ascertain the cause for it. Sometimes, your pulmonologist might also perform a transbronchial or an aspiration biopsy for confirming the diagnosis and ruling out other conditions.

Based on history, signs and symptoms, physical findings, lab findings, findings from x-ray and CT and observations from bronchoscopy, histologic findings of BAL or biopsy, your pulmonologist will arrive at a diagnosis of pulmonary eosinophilia.

Example: Your pulmonologist reviews a 62-year-old male patient with complaints of dyspnea, fever, cough and occasional incidents of hemoptysis. He says that he has been having these complaints for sometime now and they seem to be affecting his sleep and he often wakes up in the night sweating.

Your pulmonologist obtains a thorough history that includes travel history and the patient says that he has not traveled out of the country anywhere in the past few years or so.

Upon examination, your pulmonologist notices skin rash, and the presence of rhinitis. Upon auscultation, your pulmonologist notes the presence of wheezing and rales, bilaterally.

Your pulmonologist withdraws a blood sample and sends it to the lab for CBC, white blood count, differential counts and to check the level of immunoglobulin. The lab tests confirm the presence of leucocytosis with high eosinophilic counts. He also orders for chest x-ray that shows peripherally distributed alveolar infiltrates that makes him suspect that the patient is suffering from chronic pulmonary eosinophilia. He also asks for a stool sample to eliminate any infective cause for the eosinophilia.

Your pulmonologist also performs a bronchoscopy and instills saline to obtain a lavage. He sends it to the lab to rule out infections or other causes for the eosinophilia. Histologic examination of the BAL fluid confirms the diagnosis of chronic pulmonary eosinophilia.

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 pulmonary eosinophilia with J82 if you’re using ICD-10 codes or report 518.3 if you’re using ICD-9 codes.