Pulmonology Coding Alert

Hint: Coding sarcoidosis diagnosis can involve several separate tests.

Sarcoidosis is a difficult condition for physicians to diagnose, but coding the diagnosis process doesn’t have to be equally tough. This restrictive lung disease affects many different body organs and causes a variety of symptoms, including dry cough, wheezing, and fatigue.

Understand how to correctly code the sarcoidosis diagnosis process in your report.

Myth 1: Diagnosing Sarcoidosis Is a Simple Process

Pulmonary sarcoidosis is a restrictive lung disease that affects a patient’s lungs by creating abnormal stiffness and reducing the capacity of the lungs since the lungs cannot fully expand. As the disease progresses, inflammation causes granulomas (tiny lumps) to appear in the lungs. While the granulomas grow, they affect the functionality of the organ. As a result, the patient experiences breathing difficulties.

The granulomas develop most often in the lungs, but can also appear in other areas of the body, such as the eyes, skin, and lymph nodes. The effects of the disease vary from patient to patient — many people with sarcoidosis don’t have any symptoms, while others may experience mild symptoms. Since the effects vary widely from patient to patient, sarcoidosis is difficult to diagnose.

Myth 2: Imaging Results Provide All the Answers

Physicians don’t have the luxury of a one-size-fits-all diagnostic test for sarcoidosis, and they’re likely to perform several tests to confirm a diagnosis. A physician will gather the patient’s history of present illness (HPI) during an evaluation and management (E/M) visit to rule out other conditions and examine the patient for signs of sarcoidosis. The physician may also order blood tests, which can indicate changes in organ function and bone marrow.

The pulmonologist orders radiologic exams, like X-rays or computed tomography (CT) scans, to visualize the patient’s internal organs. A chest X-ray, coded to 71045-71048 (Radiologic examination, chest …), lets pulmonologists check for small round spots in the lungs and enlarged lymph nodes. Chest CT scans, coded to 71250-71270 (Computed tomography, thorax, …), may reveal scars in the lungs that are difficult to view on an X-ray.

In addition to lab work, radiological tests, or pulmonary function tests (PFTs), “pulmonologists can use bronchoscopy to help diagnose sarcoidosis,” says Carol Pohlig, BSN, RN, CPC, manager of coding and education in the department of medicine at the Hospital of the University of Pennsylvania in Philadelphia. A variety of bronchoscopy methods include:

• 31624 (Bronchoscopy, rigid or flexible, including fluoro­scopic guidance, when performed; with bronchial alveolar lavage)
• 31625 (… with bronchial or endobronchial biopsy(s), single or multiple sites)
• 31628 (… with transbronchial lung biopsy(s), single lobe)
• 31629 (… with transbronchial needle aspiration biopsy(s), trachea, main stem and/or lobar bronchus(i))

“Sometimes, endobronchial ultrasound (EBUS)-guided nodal sampling will be used,” Pohlig adds. If your provider performs an EBUS-guided nodal sampling, you’ll assign one of the two codes below:

• 31652 (Bronchoscopy, rigid or flexible, including fluoro­scopic guidance, when performed; with endobronchial ultrasound (EBUS) guided transtracheal and/or transbronchial sampling (eg, aspiration[s]/biopsy[ies]), one or two mediastinal and/or hilar lymph node stations or structures)
• 31653 (…, 3 or more mediastinal and/or hilar lymph node stations or structures)

The difference between the two codes lies in the number of stations or structures examined. You’ll assign 31652 if the pulmonologist uses an EBUS on one or two stations or structures, but if the physician examines three or more structures, you’ll assign 31653.

Myth 3: You Don’t Need to Specify the Affected Body Part

Providers who confirm a sarcoidosis diagnosis should provide the body parts affected by the disease in their documentation. “Diagnoses codes for sarcoidosis are dependent upon location and involvement,” Pohlig says. Parent code D86.- (Sarcoidosis) carries a 4th character required icon, which specifies the body part affected.

The codes for sarcoidosis are below. Note that D86.8- requires an additional character to be complete:

• D86.0 (Sarcoidosis of lung)
• D86.1 (Sarcoidosis of lymph nodes)
• D86.2 (Sarcoidosis of lung with sarcoidosis of lymph nodes)
• D86.3 (Sarcoidosis of skin)
• D86.8- (Sarcoidosis of other sites)
• D86.9 (Sarcoidosis, unspecified)

Scenario: A patient presents to a pulmonology practice experiencing dry cough, shortness of breath, fever, fatigue, swollen lymph nodes, and sudden weight loss. The pulmonologist performs a physical examination, takes blood work, and orders chest X-rays. While reviewing the views of the X-rays, the pulmonologist notices small lumps in the lungs and lymph nodes. The physician then diagnoses the patient with sarcoidosis of the lungs with sarcoidosis of the lymph nodes.

For this scenario, you’ll assign D86.2 for the confirmed diagnosis of sarcoidosis. ICD-10-CM code D86.2 is a combination code, which includes sarcoidosis of the lungs and sarcoidosis of the lymph nodes. However, before you select the code, the confirmed diagnosis in both organs must be present and documented in the provider’s report.

What if the provider doesn’t specify which body part is affected by sarcoidosis? You should query the physician and double-check the documentation to see if that information was accidentally left out. Pohlig adds, “Refrain from using D86.9, especially when sarcoidosis can affect many organ systems, and can be confirmed through testing.” A more specific diagnosis should be used, when applicable. Educating the physician on these options will help improve documentation.

Myth 4: Coding Signs and Symptoms Is Unnecessary

If the physician is unable to confirm a sarcoidosis diagnosis, then you should code the signs and symptoms the patient is presenting. “Prior to definitive results (in the rule-out phase), use signs or symptoms to report the visits or tests being provided,” Pohlig says. According to ICD-10-CM Official Guidelines, Section I.B.4, you should code the signs and symptoms “when a related definitive diagnosis has not been established (confirmed) by the provider.”