Pulmonology Coding Alert

What You Need to Know

Pulmonology coders will finally be able to report various asthma and chronic bronchitis conditions with greater specificity - thanks to new and revised ICD-9 codes that take effect Oct. 1. CMS unveiled the new diagnosis codes, several of which affect pulmonology practices, in the May 19 Federal Register.

The new and revised asthma diagnosis codes have something in common: more precise fifth-digit definitions.

Medicare focused on asthma for many of its pulmonology-related updates because asthma is a high-profile condition for patients, physicians and payers, says Anthony M. Marinelli, MD, FCCP, chairman of the American Thoracic Society's Clinical Practice Committee. Someday, CMS and other carriers may use the data from ICD-9 reports to adjust payments or develop quality guidelines. That's why your pulmonology practice should be as accurate as possible when you report diagnosis codes to avoid a potential fraud or abuse issue, he adds.
 
Link CVA Diagnosis With Bronchodilator Treatment

You will have several new respiratory diagnosis codes to choose from in 2004. CMS will add cough variant asthma (CVA) (493.82), a form of asthma with a chronic cough, and acute chest syndrome (517.3), which is most often associated with sickle-cell disease.

For example, your pulmonologist might report a CVA diagnosis if a patient presented with a chronic cough (786.2) lasting longer than three weeks, although the patient showed no other asthmatic symptoms, such as shortness of breath (786.05) or wheezing (786.07), says Carol Pohlig, BSN, RN, CPC, senior coding and education specialist at the University of Pennsylvania department of medicine in Philadelphia.

Typically, your physician can choose from several carrier-approved procedures to test for CVA. For instance, your pulmonologist tests the patient with bronchodilators (94640, Pressurized or nonpressurized inhalation treatment for acute airway obstruction or for sputum induction for diagnostic purposes [e.g., with an aerosol generator, nebulizer, metered dose inhaler or intermittent positive pressure breathing (IPPB) device]) and performs a bronchial challenge (95070, Inhalation bronchial challenge testing [not including necessary pulmonary function tests]; with histamine, methacholine, or similar compounds). He or she finds eosinophilic inflammation (518.3), and rules out CVA. You would report the diagnostic tests and the eosinophilic diagnosis.

Your physician will most likely encounter acute chest syndrome in patients with sickle-cell anemia. For example, a sickle-cell patient presents to your office with a number of signs and symptoms: chest pain (786.5x), cough (786.2), progressive anemia (285.9), hypoxemia (799.0) and new infiltrates found on x-ray (793.1, Lung field). The patient may have fever (780.6), as well.

When your pulmonologist diagnoses a patient with severe acute respiratory syndrome (SARS), you will be able to report a specific SARS-related condition, as opposed to only signs and symptoms. Medicare has introduced three new SARS codes: 079.82 (SARS-associated coronavirus), 480.3 (Pneumonia due to SARS-associated coronavirus), and V01.82 (Exposure to SARS-associated coronavirus).

You can't report the SARS codes for past SARS cases, Pohlig says. "The codes do not represent a past history of SARS, but rather a current, acute illness."

Physicians should report SARS cases using signs and symptoms or complications until the new codes take effect. For example, a patient with an advanced case of SARS develops pneumonia (480.x) and respiratory syncytial virus (079.6). Your pulmonologist would use these diagnoses to report the patient's condition, whereas after Oct. 1, your physician can list 480.3 to clearly identify a SARS-related condition.

And, until the new codes take effect, you could link either 079.89 (Other specified viral infection) or 079.99 (Unspecified viral infection) if a patient presents with a SARS-related illness, Marinelli says.
 
Choose Specific Bronchitis Exacerbation Levels

The ICD-9 changes will allow your physician to more accurately determine a chronic bronchitis patient's level of exacerbation. CMS offers revised descriptors for 491.20 (Obstructive chronic bronchitis, without exacerbation) and 491.21 (...with [acute] exacerbation), which means if you report 491.20 after Oct. 1, you must know whether the patient has acute exacerbation, whereas now the 491.20 signifies "without mention of exacerbation," Pohlig says.

Also, your pulmonologist will not be stuck with choosing only acute exacerbation for obstructive chronic bronchitis.

Beginning in October, you will be able to report several asthma codes with more specific fifth digits: 493.00 (Extrinsic asthma, unspecified), 493.02 (...with [acute] exacerbation), 493.10 (Intrinsic asthma, unspecified), 493.12 (...with [acute] exacerbation), 493.20 (Chronic obstructive asthma, unspecified), 493.22 (...with [acute] exacerbation), 493.90 (Asthma, unspecified; unspecified), and 493.92 (...with [acute] exacerbation).

Prior to October, if your physician selected a fifth digit for one of the above asthma or bronchitis codes, the digit could represent several conditions: For example, if your physician added "0" to 493.1, this diagnosis could mean without mention of status asthmaticus, acute exacerbation, or unspecified, Pohlig says.
  
Use New V Codes for Inoculations

You will need to report a five-digit diagnosis code for patients needing inoculations for compromised immune systems. Codes V04.81 (Need for prophylactic vaccination and inoculation, influenza), V04.82 (...respiratory synctial virus [RSV]) and V04.89 (...other viral diseases) replace V04.8 (Need for prophylactic vaccination and inoculation against certain viral diseases, influenza).

Your pulmonologist should use V04.81, V04.82 and V04.89 only for vaccinations, Marinelli says. For example, if your pulmonologist vaccinated a patient who ran a risk for influenza (487.x), you would report G0008 (Administration of influenza virus vaccine ...) for Medicare patients, or 90471 (Immunization administration [includes percutaneous, intradermal, subcutaneous, intramuscular and jet injections]; one vaccine [single or combination vaccine/toxoid]) for most private insurers. You would link the diagnosis V04.81 to the procedure.

Medicare may have added V04.81-V04.89 to separate these inoculation codes from other routine vaccinations, such as hepatitis A (Medicare covers hepatitis B), which CMS and other carriers may not cover, says Linda L. Lively, MHA, CCS-P, RCC, CHBME, president and CEO of AMAC, a coding consultant firm in Atlanta.