What your pulmonologist writes in the documentation matters.
The pulmonologist’s documentation, along with the patient’s medical record can make or break your chronic obstructive pulmonary disease (COPD) reporting. One key is making sure that your coding accurately identifies the patient’s specific pulmonary condition and any other associated acute condition (if necessary).
Background: According to the National Heart Lung and Blood Institute, COPD is a serious lung disease that, over time, makes it hard to breathe. In people who have COPD, the airways — the bronchial tubes through which air moves in and out of your lungs — are partially blocked, which makes it more difficult to get air out than in.
These hints will help you determine which ICD-9 codes you should report when the patient has other conditions that are related to COPD.
Hint 1: Category 493 Fits COPD and Asthma
Asthma is a disease distinct from COPD. However, the two may co-exist in the same patient. The ICD-9 493 category includes all the asthma codes you might need. If your pulmonologist diagnoses COPD and asthma together, look to the terms he uses in the medical record and use them as your guide to select which code to report.
The asthma codes you’ll choose from are:
- 493.20 — Chronic obstructive asthma, unspecified
- 493.21 — Chronic obstructive asthma with status asthmaticus
- 493.22 — Chronic obstructive asthma with acute exacerbation.
Heads up: You might find some confusion about selecting 493.20, a less-specific code. You should clarify with the pulmonologist if the patient has status asthmaticus or an acute exacerbation before opting to go for the “default” code. If the patient does not have either of these two conditions, only then should you use 493.20. Underdocumented details may affect the most specific ICD-9 code selection.
Additionally, if your pulmonologist documents status asthmaticus with any type of COPD, you should list that diagnosis first. The status asthmaticus diagnosis “supercedes any type of COPD, including that with acute bronchitis or acute exacerbation,” says Deborah J Grider, CMA, CPC, CPC-H, CPC-P, CCS-P, CCP, EMS, president of Indianapolis-based Medical Professionals Inc and author of the American Medical Association’s Principles of ICD-9-CM Coding. You should only assign the fifth digit of “1″ in this case (493.21), not the fifth digit of “2″ (493.22).
Hint 2: COPD + Bronchitis = 491.2x
Chronic obstructive bronchitis is a more specific diagnosis than the non-specific term, COPD (496). If your pulmonologist documents chronic obstructive bronchitis in a patient, you should bill 491.2x (Obstructive chronic bronchitis: 0 without exacerbation, 1 with (acute) exacerbation and 2 with acute bronchitis).
Note: The CPT code 466.0 (Acute bronchitis) is no longer necessary to report in the setting of chronic obstructive bronchitis since the descriptor for 491.2x already mentions “acute bronchitis.”
It is possible that the pulmonologist would document that a patient is having acute bronchitis with COPD which is causing an acute exacerbation. When faced with this scenario, remember that the acute bronchitis causes the exacerbation, thus you should still report 491.22 (Obstructive chronic bronchitis with acute bronchitis), says Alan L Plummer, MD, professor of medicine in the division of pulmonary, allergy, and critical care at the Emory University School of Medicine in Atlanta, Georgia.
On the other hand, if the documentation states that the patient has COPD with acute exacerbation, but doesn’t mention acute bronchitis, report 491.21 (Obstructive chronic bronchitis, with [acute] exacerbation).
Example: A patient with COPD who is not well-controlled is just using an albuterol inhaler. The pulmonologist decides to add a steroid inhaler to current therapy along with a long-acting beta-2 agonist. You could report the encounter using only 496 (Chronic airway obstruction, not elsewhere classified), but a more descriptive code would be 491.21. This code specifically identifies the patient as having chronic obstructive bronchitis and indicates that the patient’s clinical problems are not controlled.
Important: If the diagnoses states only COPD, with no other manifestation or condition associated with it (i.e., chronic bronchitis or emphysema), you should opt for 496. If the patient has emphysema in addition to chronic obstructive bronchitis, you should also code 491.2x since this code also includes emphysema. If the patient does not have chronic bronchitis but does have emphysema, you should code 492.8 (Other emphysema).
Hint 3: Documentation Must Jive With COPD Diagnosis
If you’re going to list a COPD diagnosis code, be sure the documentation supports the physician’s code selection. You should look out for details in the documentation, such as a listing of signs, symptoms and conditions. Play it safe by having enough detail in the history of present illness and the review of systems to support a diagnosis of COPD.
Watch for: Your pulmonologist should also document the tests he orders, such as X-rays (71010-71035), and pulmonary function tests (94010-94621). Document any therapeutic drug treatment associated with the plan of care for the patient. The tests and treatments help support your physician’s diagnosis of COPD.
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