Pulmonology Coding Alert

Question: A patient came in for a follow-up evaluation and management (E/M) visit for their moderate persistent asthma. Two months ago, the physician prescribed albuterol to the patient to treat their asthma. During the most recent encounter, the physician asked how the patient is feeling with the medication. The patient stated they haven’t been taking the medication because they lost their job and haven’t been able to afford the prescription. The physician documented this information in the record.

What diagnosis codes should I use to report this encounter?

Mississippi Subscriber

Answer: You’ll need to assign two codes for this encounter — J45.40 (Moderate persistent asthma, uncomplicated) and Z91.190 (Patient’s noncompliance with other medical treatment and regimen due to financial hardship).

Code Z91.190 was added to the 2023 ICD-10-CM code set and took effect on Oct. 1, 2022. This code allows you to indicate that the patient is responsible for their noncompliance with their medication or other treatment regimen. Greater attention is being drawn to the patients’ social determinants of health (SDOH) and expanding code subcategories allow providers and coders to specify the why behind the SDOH.

However, it’s important to remember that you should assign only codes that relate to the care of the patient. The ICD-10-CM Official Guidelines tell us to assign as many codes as “necessary to describe all the problems or risk factors, but they should only be assigned if the documentation specifies that [the patient has] an associated problem or risk factor. So, we want to be careful in how we’re using those SDOH,” said Jill Young, CEMC, CPC, CEDC, CIMC, of Young Medical Consulting LLC in East Lansing, Michigan during AAPC’s “ICD-10-CM Updates for 2023” webinar.