Pulmonology Coding Alert

Hint: Focus on acute conditions, exacerbations

The key to correctly reporting asthma, bronchitis and chronic obstructive pulmonary disease (COPD) lies in the pulmonologist's documentation and 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.

Look to 493 for Asthma With COPD

One condition that can be associated with asthma is COPD. You can find all of the asthma codes in the 493 category of ICD-9 codes. When your physician diagnoses both COPD and asthma together, you'll refer to his documentation in the medical record to settle on a code. The three asthma codes you'll choose from are:

• 493.20 -- Chronic obstructive asthma; unspecified

• 493.21 -- Chronic obstructive asthma; with status asthmaticus

• 493.22 -- Chronic obstructive asthma; with (acute) exacerbation.
 
Note: Most payers don't like unspecified codes such as 493.20, so ask your pulmonologist whether the patient has status asthmaticus or an acute exacerbation so you can avoid using the unspecified code. If the patient doesn't have either of those manifestations, your only option is to use 493.20.
 
If your pulmonologist documents status asthmaticus with any type of COPD, you should report this diagnosis first. Assign the fifth digit of "1" in this case (493.21,  Chronic obstructive asthma; with status asthmaticus), not the fifth digit of "2" (493.22), says Cheryl Klarkowski, RHIT, coding specialist with Baycare Health Systems in Green Bay, Wis.
 
In black and white: The status asthmaticus should be reported because it indicates the most acute form of the patient's condition, according to chapter 8, section 1C of the ICD-9-CM Guidelines. "It supersedes any type of COPD including that with acute exacerbation 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 asthmatics. Only the fifth-digit '1' should be assigned."

Use 491.22 for COPD and Bronchitis

Another common condition that patients can have that is associated with COPD is bronchitis. When your physician documents chronic obstructive bronchitis with an episode of acute bronchitis, you should report 491.22 (Obstructive chronic bronchitis; with acute bronchitis), Klarkowski says. You don't have to report 466.0 (Acute bronchitis) for the obstructive chronic bronchitis since the code descriptor for 491.22 specifies acute bronchitis.
 
Tip: If your pulmonologist 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) or the acute condition alone (466.0), according to the ICD-9-CM Guidelines.
 
Therefore, you should still report 491.22. 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.
 
Exception: If your pulmonologist diagnoses COPD and there are no other manifestations or conditions such as chronic bronchitis or emphysema that are associated with COPD, you should use 496 (Chronic airway obstruction, not elsewhere classified).

Support COPD Dx With Documentation

If you're going to list a COPD diagnosis code, be sure the documentation includes a listing of signs, symptoms and conditions.
 
"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, is of prime importance. Once clinically suspected, blood studies, along with radiographical and physiological evaluations, will complement the workup in order to make a diagnosis."
 
Your pulmonologist 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 a diagnosis of COPD before reporting it.
 
Taking a full past medical history and identifying family history and social history are also important steps when your physician performs an E/M service on a patient with COPD. For more information on documentation for COPD, see our article "Look for Keywords to Understand  COPD" on page 44.