Advanced Search

Pulmonology Coding Alert

Take a Deep Breath When Seeking Reimbursement for Pediatric Asthma

Published on Mon Oct 01, 2001

Pediatric asthma is being treated more frequently by pulmonologists as well as allergists. According to Dr. Miles Weinberger, professor of pediatrics and director of the Pediatric Allergy and Pulmonary Division of the University of Iowa Hospital, this condition affects 15 to 25 percent of all children and accounts for 15 percent of their nonsurgical hospitalizations. 
 
Coding for pediatric asthma is complicated not only by the age of the patient but because it cannot be diagnosed before the age of 2 or 3. The first year or two is spent monitoring and recording the child's symptoms. Only after repeated episodes of chest symptoms can the condition be diagnosed.

History, Decision-Making and Severity Affect E/M Coding 
 
A 3-year-old boy presents to the pulmonologist after repeated episodes of wheezing, coughing, shortness of breath, and tightness in his chest. His visit is coded with E/M codes 99201-99205 if he is a new patient, 99211-99215 if an established one, or 99241-99245 if the physician has been called in as a consultant. 
 
"Although any level of these E/M codes can be used, this visit will probably be coded higher rather than lower," Weinberger says. Both the severity of the presenting problem -- the compromised respiratory function of a child -- and the complex level of decision-making indicated by the battery of diagnostic tests that will need to be ordered may support a higher-level E/M code.
 
The extent of the medical history required also supports coding at a higher E/M level. According to Dr. Linda Ford, recent president of the American Lung Association and director of the Asthma and Allergy Center in Papillion, Neb., the medical history of the child plays the most important role in the initial diagnosis of pediatric asthma and must be comprehensive in detail.
 
"The history is usually extensive  because it is important to establish the timing of the symptoms in relation to seasonal patterns and exercise in addition to obtaining a family history indicating a susceptibility to asthma," Ford says. While parents provide this information for very young children, she says it is important to have older children provide their own information. "Older children sometimes give different information than their parents, especially about wakefulness at night," she says.
 
Because the history is so important in diagnosing this condition, practices must  make sure the documentation supports the amount of information obtained and the effort spent on the patient to ensure fair and complete reimbursement.

Determining the Most Appropriate Diagnosis
 
 
The physical examination of the patient concentrates on the lungs, upper airways, eyes, ears, nose (particularly the nasal passages) and throat. However, since the caliber of the airways cannot be estimated or evaluated from this information alone, spirometry (94010) is performed to supply the objective assessment needed for the diagnosis. Even though this procedure can help, usually more information, primarily pinpointing reversibility, is needed to determine the severity and confirm the diagnosis of the condition. Thus, an aerosolized inhalation of a broncho-dilator is often used in connection with spirometry, a procedure coded 94060 (bronchospasm evaluation: spirometry as in 94010, before and after bronchodilator [aerosol or parenteral]).
 
A child older than 5 years should be able to participate in a spirometric maneuver. For younger children who may not be able to participate in spirometry, the diagnosis will need to be made on history and physical examination only.
 
Coding the diagnosis of the condition is tricky. Most physicians classify pediatric asthma using the National Institutes of Health (NIH) guidelines, which categorize it according to severity: intermittent, mild persistent, moderate persistent and severe persistent. 
 
The ICD-9 codes have a different classification system. According to the ICD-9 manual, the basic code for asthma is 493 (transient narrowing of the airway diameters in the bronchial tree, restricting airflow and causing labored breathing and wheezing).  A fourth digit is then added, classifying asthma as either extrinsic (493.0), intrinsic (493.1), chronic obstructive (493.2) or unspecified (493.9). The fifth digit subclassifies the condition still further with a final 0 indicating no mention of status asthmaticus; a 1, status asthmaticus; or a 2, acute exacerbation.
 
The coding problem is to reconcile the two classification schemes. Coders must translate the category assigned by the pulmonologist into the appropriate ICD-9 code to receive proper reimbursement. According to Ford, the most frequently used code is 493.02 because "most of our current knowledge indicates that asthma is caused by an allergic reaction to something in the environment rather than a response to something internal as suggested by intrinsic asthma."
 
In addition to spirometry, skin testing may be used to diagnose pediatric asthma because, Weinberger says, "Children with asthma are frequently allergic to other things as well."
 
"Skin testing, which can be done at any age, can identify sensitivities to a variety of indoor and outdoor allergens," Ford says. "The trick is to tailor the environmental controls to the child and the possible allergens."
 
If skin testing is performed it is coded one of two ways, depending on how it is administered, either as 95004 (percutaneous tests [scratch, puncture, prick] with allergenic extracts, immediate type reaction, specify number of tests) or 95024 (intracutaneous [intradermal] tests with allergenic extracts, immediate type reaction, specify number of tests).

Coding for Therapy
 
Once pediatric asthma has been diagnosed and an acute episode occurs, it is treated with inhalation therapy. For example, a 5-year-old child presents to the pulmonologist with acute shortness of breath and wheezing. He is administered the appropriate therapy, which is coded 94640 (nonpressurized inhalation treatment for acute airway obstruction). 
 
The key to interpreting this code is the word "obstruction." In this instance it is not limited to something physical like a tumor interfering with the airway; it also includes swelling of the airway passages that compromises respiratory function. If the child requires a subsequent treatment because after 15 minutes his breathing has not improved, this second procedure would be coded 94640 with modifier -76 (repeat procedure by same physician) added to indicate the second service. 
 
Older children may be prescribed a metered-dose inhaler for daily control of their condition. For example, a 10-year-old girl presents at the pulmonologist with wheezing and tightness in the chest. To treat her condition, inhalation therapy is administered and she is taught how to use an inhaler. The first part of the procedure, the treatment, would be coded 94640 with modifier -59 (distinct procedural service) appended, indicating that the medication is being administered to relieve the wheezing and tightness in the chest.
 
The second part of the procedure, the education of the patient, would be coded 94664 (aerosol or vapor inhalations for sputum mobilization, bronchodilation, or sputum induction for diagnostic purposes; initial demonstration and/or evaluation). Fifteen minutes later,  breathing has still not improved, so additional therapy is administered. This second procedure would be coded 94640, with modifiers -59 and -76 attached. If the young patient requires additional education, that service would be coded 94665 (... subsequent).
 
Note: Many carriers will accept 94664 only once per patient's lifetime under the same physician with the same device.

Other Articles in this issue of

Pulmonology Coding Alert

View All