Pulmonology Coding Alert

Question: We performed spirometry and the doctor wrote that it was for “chronic bronchitis,” but we don’t see that listed on our payer’s local coverage determination. Can you advise what we should do?

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Answer: Pulmonologists use spirometry (94010,  Spirometry, including graphic record, total and timed vital capacity, expiratory flow rate measurement[s], with or without maximal voluntary ventilation) and 94060 (Bronchodilation responsiveness, spirometry as in 94010, pre- and post-bronchodilator administration) to measure how quickly the patient’s lungs can move air in and out, as well as how much. Although the payment for spirometry tests is based on the CPT^® codes you report and not on the diagnosis, the payer can easily reject your claim if you can’t establish a credible medical necessity for the procedure by applying the correct diagnosis code.

Because you refer to “chronic bronchitis” in your question, it’s possible that you didn’t select an ICD-10 code that was chosen to the highest possible level of specificity by collecting complete information. While you are converting the physician’s encounter information into codes, you need to have complete information at your hands.

For example, if the doctor simply writes “chronic bronchitis” in the patient’s record, you need more information. Chronic bronchitis is a very non-specific diagnosis and most likely to be denied because of missing digits. ICD-10 classifies chronic bronchitis through either of the J41 (Simple and mucopurulent chronic bronchitis), J42 (Unspecified chronic bronchitis), or J44 (Other chronic obstructive pulmonary disease) family of codes. You need determine the type of chronic bronchitis (simple, mucopurulent, with/without exacerbation, etc.) and whether it is a confirmed diagnosis. Consequently, you will have to seek more information on the specific symptoms from the patient’s chart or by querying the physician. Specific diagnosis coding requires clear access to all the necessary information.

Use the code with the highest specificity: No matter how well the pulmonologist communicates the patient data, you must ensure that you use the right code and that it is being carried to the highest digit possible. This involves not only noting any caution or warning symbols in the ICD-10 manual (some color-coded books use yellow for nonspecific codes and red for those with missing digits) but also having a good working knowledge of the terminology associated with spirometry. From the example above, if the physician sees a patient for chronic bronchitis, you will have to support the diagnosis codes by gathering enough information to know that the patient has obstructive chronic bronchitis with acute exacerbation.

Find the correct and complete code under chronic bronchitis with acute exacerbation (J41, J42, J44). The simple rule is: Assign higher-level codes only if there are no sub-codes within that code category. For example, assign four-digit codes only if there are no fifth-digit subclassifications for that category. Otherwise, assign the closest fifth-digit subclassification code for those categories where it exists.