Pulmonology Coding Alert

Hint: Exclusions remains the same as in ICD-9 codes

You regularly see patients for shortness of breath, so knowing how to handle dx coding once ICD-10 comes into play will be vital. There are many different conditions that can cause shortness of breath (dyspnea) and one such is emphysema (one type of chronic obstructive pulmonary disease " COPD).

Review These Symptoms and Diagnostic Test Details

When your pulmonologist diagnoses emphysema, you will probably see some of these symptoms that he will note in the patient charts: chronic shortness of breath (R06.02, Shortness of breath) that is gradually increasing over a period of time; an expanded chest (barrel chest); tachypnea (rapid breathing); and cough (R05, Cough) with sputum production.

Upon auscultation, you pulmonologist will observe hyperresonant breath sounds. There might also be signs of cyanosis.

Your pulmonologist will order a chest x-ray and blood tests (to check WBC counts and to check for alpha-1-antitrypsin deficiency) and arterial blood sample to check for arterial blood gases. You pulmonologist will also undertake pulmonary function tests such as spirometry (94010, Spirometry, including graphic record, total and timed vital capacity, expiratory flow rate measurement[s], with or without maximal voluntary ventilation), diffusing lung capacity-DLCO (+94729, Diffusing capacity [e.g., carbon monoxide, membrane][List separately in addition to code for primary procedure]) and plethysmography ( 94726, Plethysmography for determination of lung volumes and, when performed, airway resistance).

Identify Type in ICD-9

When your pulmonologist arrives at a diagnosis of emphysema, you will need to code the diagnosis with 492 (Emphysema). Based on the type of emphysema, you will need to use a 4th digit expansion and report emphysema using the following codes:

• 492.0 (Emphysematous bleb) -- This code will include diagnosis of giant bullous emphysema, ruptured emphysematous bleb, tension pneumatocele and vanishing lung
• 492.8 (Other emphysema) -- This code will include diagnosis of centilobular, panlobular, unilateral (MacLeod's syndrome) and vesicular type of emphysema.

Code Exposure to Tobacco in ICD-10

When ICD-10 codes come into use, 492 in ICD-9 will transform to J43 (Emphysema) in ICD-10 code sets. If your diagnosis is 492.0, you will need to report J43.9 (Emphysema, unspecified) when you start using ICD-10 codes. 492.8 under ICD-9 will further expand into 4 additional codes in ICD-10 that specify the type of emphysema:

• J43.0 (Unilateral pulmonary emphysema [MacLeod's syndrome])
• J43.1 (Panlobular emphysema)
• J43.2 (Centrilobular emphysema)
• J43.8 (Other emphysema)

Note: You will need to additionally code any exposure to environmental tobacco (Z77.22, Contact with and [suspected] exposure to environmental tobacco smoke [acute] [chronic]), history of tobacco use (Z87.891, Personal history of nicotine dependence), tobacco dependence (F17._, Nicotine dependence), tobacco use (Z72.0, Tobacco use) and occupational exposure to environmental tobacco (Z57.31, Occupational exposure to environmental tobacco smoke) in addition to the diagnosis codes when you begin using ICD-10 codes.

You will have to look for specific documentation from your physician in case another related series of emphysema codes (i.e., J43 exclusions) better represent your patient's condition:

• compensatory emphysema (J98.3)
• emphysema due to inhalation of chemicals, gases, fumes or vapors (J68.4)
• emphysema with chronic (obstructive) bronchitis (J44.-)
• emphysematous (obstructive) bronchitis (J44.-)
• interstitial emphysema (J98.2)
• mediastinal emphysema (J98.2)
• neonatal interstitial emphysema (P25.0)
• surgical (subcutaneous) emphysema (T81.82)
• traumatic subcutaneous emphysema (T79.7)

Example: A 62-year-old male patient arrives at your pulmonologist's office after relocating from another state. He does not have any prior records with him. He complains of shortness of breath that has been there for many years and is gradually increasing over time. He complains that he is now needs to stop to catch his breath to undertake the slightest of physical activities. When your pulmonologist records the history, he notes that the patient does not have the habit of smoking although he is exposed to cigarette smoke as he was employed until recently as a bartender in the local pub for the past 23 years.

Your pulmonologist finds the appearance of barrel chest upon examination. Upon auscultation, your pulmonologist notes hyperresonant breath sounds. He suspects a diagnosis of emphysema and orders a chest x-ray, withdraws a venous blood sample and an arterial blood sample and sends it to the lab for diagnosis.

He also performs pulmonary function tests (spirometry, plethysmography and DLCO). Upon review of the diagnostic test results and the results of lab tests along with the x-ray interpretations, your pulmonologist is able to confirm a diagnosis of centrilobular emphysema. You code the diagnosis with J43.2 along with Z57.31.