Pulmonology Coding Alert

Question: Parents of an 8-month-old infant present to the hospital emergency department (ED) because the child is having difficulty breathing and wheezing while breathing. After recording the patient’s history and performing a physical examination, the pulmonologist documents their findings of a fever, tachypnea, and tachycardia as well as wheezing sounds heard during auscultation.

Due to the patient’s age, symptoms, and the number of episodes of acute bronchiolitis in the area, the pulmonologist documents a preliminary diagnosis of acute bronchiolitis. Lab testing later confirmed a diagnosis of acute bronchiolitis due to RSV.

What diagnosis code should I assign?

Kentucky Subscriber

Answer: As you indicated the lab reports confirmed the pulmonologist’s diagnosis, you’ll assign J21.0 (Acute bronchiolitis due to respiratory syncytial virus). The code features an additional synonym of “Acute bronchiolitis due to RSV.” Your provider may abbreviate respiratory syncytial virus as RSV in their documentation, so you should query them if you’re unsure of any abbreviations.

Parent code J21.- (Acute bronchiolitis) features an Includes note that covers acute bronchiolitis with bronchospasm. Additionally, the Excludes2 note for J21.- allows you to code J84.115 (Respiratory bronchiolitis interstitial lung disease) along with J21.0 if the patient is also suffering from that condition along with acute bronchiolitis.