Pulmonology Coding Alert

Starting Oct. 1, you can start using several new diagnosis codes to describe a chronic pulmonary artery clot, unusual flu strains, and failed sedation procedures to better document your pulmonologist's services.

Here's the skinny:

Add 416.2 (Chronic pulmonary embolism) to your repertoire of diagnosis codes. Report the new pulmonary embolism code when a patient with unexplained dyspnea (786.09) or with a history of pulmonary hypertension (416.8) displays evidence of pulmonary embolism on a CT scan or pulmonary angiogram, without evidence of a recent event, explains Philip Marcus, MD, MPH, FACP, FCCP, chief of pulmonary medicine at the St. Francis Hospital Heart Center in Roslyn, N.Y.

The difference: Use 416.2 to explain chronic symptoms, as opposed to the finding of a new, acute pulmonary embolism, which would necessitate reporting either 415.11 (Iatrogenic pulmonary embolism and infarction), 415.12 (Septic pulmonary embolism), or 415.19 (Pulmonary embolism and infarction; other).

Differentiating between an old or chronic thrombus (416.2) and a new, or acute, thrombus allows you to document the need for continuation of an established therapy versus initiation or intensification of anticoagulant therapy, according to an Agency for Healthcare Research and Quality Coordination and Maintenance Committee statement.

V code: The V code (V12.51, Personal history of venous thrombosis and embolism) would apply when there is a history of a pulmonary embolism, but it is no longer present and not relevant to the reason for a current evaluation, Marcus clarifies.

Example 1: You may chose to report a chronic pulmonary embolism (416.2) when the pulmonologist is working up a patient with pulmonary hypertension (416.8) and finds an existing, undissolved clot in one of the pulmonary arteries, says Jill M.

Young, CPC, CEDC, CIMC, of Young Medical Consulting in East Lansing, Mich. Granted, the opportunity to report 416.2 will probably occur rarely, she adds.

Example 2: Also rely on 416.2 when a patient presents with signs and symptoms of chronic obstructive pulmonary disease (491.21) and gives a history of having a small subsegmental pulmonary embolism for which he is no longer on active therapy, Marcus offers.

Don't forget: Use 453.40 (Acute venous embolism and thrombosis of deep vessels of lower extremity, deep vein thrombosis NOS), 453.41 (Acute venous embolism and thrombosis of deep vessels of proximal lower extremity, such as femoral, thigh, upper leg NOS), or 453.42 (Acute venous embolism and thrombosis of deep vessels of distal lower extremity, such as calf or lower leg NOS) -- to describe the event leading to a pulmonary embolism, usually from a clot arising in the deep venous system of the lower extremity, notes Carol Pohlig, BSN, RN, CPC,senior coding and education specialist at the University of Pennsylvania department of medicine in Philadelphia.

In 2010, you have two new codes for reporting influenza: 488.0 (Influenza due to identified avian influenza virus) and 488.1 (Influenza due to identified novel H1N1 influenza virus).

Careful: Just because ICD-9 provides the codes doesn't mean you should use them. The 2009 coding guidelines instruct you to code only confirmed cases of avian influenza (488.1), which is an exception to the hospital inpatient guidelines (Section II.H) on uncertain diagnosis, relates Young. While "confirmation" does not require documentation of positive laboratory testing specific for avian influenza, you should base the coding on the provider's diagnostic statement that the patient has avian influenza. If the provider records "suspected or probably avian influenza," however, do not assign 488.1 -- instead, use the appropriate influenza code from 487.

"In reality, to report a specific strain, one should have proof," says Marcus. "Otherwise, it's best to report influenza (487.x) and not speculate."

Symptoms: The similarity in symptoms among various flu strains adds to the confusion. "At the present time, there are no easy ways to decide which strain of influenza is responsible for an individual infection. In fact, with the recent outbreak of H1N1 infection, most of the presumed cases were indeed negative when specifically tested for H1N1 antigen," Marcus explains.

Since the symptoms are nearly identical, consider a diagnosis of H1N1 only when other cases have been diagnosed in the area, Marcus suggests.

Invalid code: No longer report 488 (Influenza due to identified avian influenza virus). ICD-9 2010 has expanded the subcategory to 488.0 and 488.1.

ICD-9 2010 introduces two new codes to describe failed sedation attempts: 995.24 (Failed moderate sedation during procedure) and V15.80 (Personal history of failed moderate sedation).

Example: If the pulmonologist was performing a procedure such as 31622 (Bronchoscopy, rigid or flexible, with or without fluoroscopic guidance; diagnostic, with or without cell washing [separate procedure]) and the moderate sedation he administered for the procedure was not effective, then you could code 995.24, explains Alan L. Plummer, MD, professor of medicine, division of pulmonary, allergy, and critical care at Emory University School of Medicine in Atlanta.

Modifier 53: If the pulmonologists terminated the procedure before completion, using 995.24 might help support medical necessity for a shortened or aborted procedure for which you would append modifier 53 (Discontinued procedure) to 31622 and 995.24.

Going forward, this patient would now have a history of failed moderate sedation. The next time the patient had a procedure requiring sedation, you would use V15.80 to alert the pulmonologist or the anesthesiologist that the patient had had a failed moderate sedation session, Plummer notes.

Resource: View a complete list of the new and revised ICD-9 2010 codes at www.cms.hhs.gov/ICD9ProviderDiagnosticCodes/07_summarytables.asp.