Pulmonology Coding Alert

Correctly reporting asthma, acute bronchitis, chronic obstructive pulmonary disease (COPD), obstructive bronchitis, and emphysema depends on the pulmonologist's documentation in the patient's medical record. Making sure the documentation supports the patient's diagnosis and that you code for any associated acute conditions will ensure that you're correctly reporting pulmonary diagnoses.

You can find all the asthma codes in the 493 category of the ICD-9 codes. Look to 493.2x for asthma with airflow limitation. Airflow limitation may occur in asthmatic patients with persistent disease or those patients with asthma of long duration. The three asthma codes with airflow limitation demonstrated by pulmonary function testing you'll choose from are:

• 493.20 -- Chronic obstructive asthma; unspecified

• 493.21 -- ... with status asthmaticus

• 493.22 -- ... with (acute) exacerbation.

COPD can be associated with asthma. When your physician diagnoses both COPD and asthma together, you'll refer to his documentation in the medical record to settle on a code from the three codes listed above. Thus, you would use these three codes for asthma with airflow limitation or for asthma with the nonspecific diagnosis of COPD. When assigning 493.2x, follow these guidelines:

If your physician documents status asthmaticus with airflow limitation with or without COPD, you should report this diagnosis first. Assign the fifth digit of "1" in this case (493.21), not the fifth digit of "2" (493.22), says Cheryl Klarkowski, RHIT, coding specialist with Baycare Health Systems in Green Bay, Wis. Assign only an asthma code with the fifth digit "1." "Status asthmaticus" refers to a patient's failure to respond to therapy administered during an asthmatic episode and is a life-threatening complication that requires emergency care. It supersedes any type of COPD, including that with acute exacerbation (493.22) or acute bronchitis. It is inappropriate to assign an asthma code with fifth digit "2" (... with acute exacerbation) together with an asthma code with fifth digit "1" (... with status asthmaticus).

Warning: Most payers may reject unspecified codes, such as 493.20, when ICD-9 provides a more specific code. When possible, ask your physician whether the patient has status asthmaticus or an acute exacerbation to avoid using the unspecified code as a "catch-all" code for all types of asthma with airflow limitation or COPD. Remember that if the patient doesn't exhibit either manifestation, your only option is to use 493.20.

Another common condition that is associated with airflow limitation is chronic obstructive bronchitis. When your physician documents chronic obstructive bronchitis with an episode of acute bronchitis, you should report 491.22 (Chronic bronchitis; obstructive chronic bronchitis; with acute bronchitis), Klarkowski says. You shouldn't report 466.0 (Acute bronchitis) for the obstructive chronic bronchitis since 491.22's code descriptor specifies acute bronchitis.

Tip: If your physician documents that a patient has acute bronchitis with chronic obstructive bronchitis that is causing an acute exacerbation, the combined bronchitis (chronic with acute bronchitis) supersedes the exacerbation (491.21, ... with [acute] exacerbation) or the acute condition alone (466.0), according to ICD-9-CM Guidelines. Therefore, you should still report 491.22 for the acute bronchitis with chronic obstructive bronchitis.

But if the documentation states that the patient has chronic obstructive bronchitis with acute exacerbation but doesn't mention acute bronchitis, you should report 491.21. If the patient has emphysema in addition to chronic obstructive bronchitis, you should use code 491.20 (...without exacerbation) unless the patient has an exacerbation (491.21) or acute bronchitis (492.22).

Exception: If your physician diagnoses COPD and there are no other manifestations or conditions that document chronic bronchitis or emphysema, you should use 496 (Chronic airway obstruction, not elsewhere classified).

Before a COPD diagnosis code is confirmed, be sure the documentation includes a listing of signs, symptoms, and conditions to report as the reason for work-up. "Unfortunately, almost all the diseases of the lungs manifest themselves in a very similar fashion: shortness of breath and cough," says Pierre Edde, MD, founder of www.pcsbilling.com in Uniontown, Pa. "By themselves, they are not specific for any disease entity. Therefore, clinical evaluation, based on a detailed history including tobacco use past or present, is of prime importance. Once clinically suspected, radiographical and physiological evaluations will complement the workup in order to make a diagnosis."

When billing for these studies, the physician may report only the sign or symptoms that prompted the test. Do not report a "suspected" or "possible" diagnosis (for  instance, COPD) before it is confirmed. Airflow limitation documented by pulmonary function testing must be present before you can confirm COPD in a patient with a smoking history.

Your physician should document the tests he orders, such as X-rays (71010-71035) and pulmonary function tests (PFTs, 94010-94060). Make sure the physician includes enough detail in the medical record to support confirmation of the COPD diagnosis, particularly noting the pulmonary function tests (94010 or 94060).