Pulmonology Coding Alert

Question: A chronic smoker with tracheobronchitis who is on albuterol came to our office and saw the physician for an E/M service, but we aren’t sure how to find the right diagnosis code. Can you advise?

Codify Subscriber

Answer: Although this is a case of tracheobronchitis, the provider does not mention any further specifics.

If the tracheobronchitis was due to Bordetella bronchiseptica, you would code A37.80 (Whooping cough due to other Bordetella species without pneumonia), or A21.8 (Other forms of tularemia) if the causative organism was Francisella tularensi.  This code selection may be appropriate, based on the causative organism.

However, as there is no such documentation here, according to the CMS guidelines, “when a respiratory condition is described as occurring in more than one site and is not specifically indexed, it should be classified to the lower anatomic site.” So, you would report bronchitis code J40 (Bronchitis, not specified as acute or chronic) instead of tracheobronchitis.