Pulmonology Coding Alert

Question: The medical report I have lists the diagnosis as hypoxia due to a mucus plug in the respiratory system. I can never remember if I should use a foreign body code or an excessive sputum code to report the mucus plug.

Could you please help me?

Colorado Subscriber

Answer: You’ll need to assign a code for the patient’s hypoxia for this case. The mucus plug in the respiratory system is caused by the hypoxia, which means the hypoxia will be the primary and only diagnosis code used.

Assign R09.02 (Hypoxemia) to report the hypoxia diagnosis. To locate the correct diagnosis code, you’ll search for Hypoxia in the ICD-10-CM Alphabetic Index. This provides you with R09.02, which you’ll verify in the Tabular List.

When you turn to the Tabular List, you’ll notice the code’s descriptor lists hypoxemia. Hypoxia refers to a reduced oxygen supply to the body tissue, whereas hypoxemia occurs when the blood is oxygen deficient. While the two terms are similar, they are not the same condition, but you will use the same ICD-10-CM code for the conditions.

A mucus plug is not considered a foreign body since it originates within the patient and builds up in the respiratory system. Additionally, you won’t assign a corresponding code (e.g., T17.5- Foreign body in bronchus) to represent the mucus plug code unless it severely impairs the patient’s breathing to the point of documented asphyxiation.