COPD

This month’s “In the kNOW” article will address the coding of COPD.  Chronic obstructive pulmonary disease is a condition that affects the lungs.  It may be chronic bronchitis or emphysema.  Chronic bronchitis causes the airways to narrow due to inflammation, while emphysema impacts the alveolar sacs in the lungs by trapping air and compromising the ability to exhale completely.  This causes the reduction of oxygen available to circulate throughout the body.

In ICD-10-CM coding of COPD is based on the complete diagnostic statement.  If the only condition documented is COPD, the proper code assignment is J44.9.  If the physician documents COPD and emphysema, then the coding professional should assign J43.9.  The rationale for this is explained in a 4^th Qtr. 2017 Coding Clinic, which states that emphysema is a specific type of COPD.  Therefore, when both conditions are documented, code the more specific diagnosis only, J43.9. 

If COPD is documented along with a lower respiratory infection, such as pneumonia or bronchitis, then the COPD is coded as J44.0.  Remember, this applies only to COPD with a lower respiratory infection.  So, if the patient has influenza, we would not assign J44.0 since influenza is considered an upper and lower respiratory infection.  Additionally, do not assign J44.0 if COPD is documented with aspiration pneumonia.  That type of pneumonia is considered a lung disease due to an external cause rather than a lower respiratory infection. 

There are instances when COPD suddenly becomes worse for a period of time.  This is called an acute exacerbation.  When COPD is in acute exacerbation, the appropriate code is J44.1.  There may be instances when a patient is suffering from both an acute exacerbation of COPD and a lower respiratory infection.  In those circumstances, assign both J44.0 and J44.1 along with the code specifying the lower respiratory infection (ie. acute bronchitis).

When asthma is present in a patient with COPD, assign only code J44.9.  This is true unless the patient’s asthma is specified by type such as mild persistent asthma, in which case assign both the COPD code (J44.9) and the specific asthma code (J45.30).   If the patient’s asthma is stated as being in acute exacerbation, coding professionals may assign both J44.9 and J45.901.  The 4^th Qtr. 2017 Coding Clinic indicated the appropriateness of this code assignment by stating that the diagnosis of acute exacerbation of asthma not further qualified is, in itself, a specific type of asthma.  Therefore, the code assignment of J45.901 along with J44.9 is acceptable. 

Now you are In the kNOW!!

About the Author 

Dianna Foley, RHIA, CHPS, CCS  is OHIMA's Coding Education Coordinator. Dianna has been an HIM professional for 20 years. She progressed through the ranks of coder, department supervisor, and department director, to her current role as a coding consultant. 

She recently served as the program director for Medical Coding and HIT at Eastern Gateway Community College. Dianna earned her bachelor's degree from the University of Cincinnati subsequently achieving her RHIA, CHPS, and CCS certifications. She is an AHIMA Approved ICD-10-CM/PCS Trainer and a a presenter at regional HIM meetings and the OHIMA Annual Meeting.

Dry Needling

Every year CPT publishes new codes with which coding professionals must become familiar.  In this edition of Spotlight on CPT, two codes that were new for 2020 will be discussed.  They are 20560 and 20561 for needle insertion(s) without injection(s).

I’ll confess that I had to do some research to see why a code was needed for needle insertions if no injection was being done, and that’s how I became aware of a procedure called dry needling.  In order to get a picture of dry needling, think acupuncture.  Now, it is not exactly the same, with the main difference being that during a dry needling procedure the needles are not left in for very long in contrast to acupuncture where the needles are left in anywhere from 20-25 minutes.  However, the goal is the same which is pain relief.

Dry needling is performed by physical therapists with filiform needles which are very fine and similar to what is used in acupuncture.  These stainless-steel needles are short and inserted in myofascial trigger points to stimulate muscles and relieve pain.  Therapists may use a pecking method, rapid in and out movement with the needles, to stimulate the muscle or tissue. 

How does this help relieve pain?  Well, trigger points which are muscle contractures or bands can be disrupted by this process reducing the trigger point and even increasing blood flow to the area. 

These codes are structured similarly to the codes for trigger point injections with code 20560 for needle insertion(s) into one or two muscles and code 20561 for three or more muscles.   

The procedure may not be covered by insurance, but is gaining in popularity.  And now, we have CPT codes to report those instances when it is performed. 

Now, light has been shed on dry needling.

 

About the Author 

Dianna Foley, RHIA, CHPS, CCS  is OHIMA's Coding Education Coordinator. Dianna has been an HIM professional for 20 years. She progressed through the ranks of coder, department supervisor, and department director, to her current role as a coding consultant. 

She recently served as the program director for Medical Coding and HIT at Eastern Gateway Community College. Dianna earned her bachelor's degree from the University of Cincinnati subsequently achieving her RHIA, CHPS, and CCS certifications. She is an AHIMA Approved ICD-10-CM/PCS Trainer and a a presenter at regional HIM meetings and the OHIMA Annual Meeting.

ASK HIM: Hospital Admission Dates for ED Patient

Question from Dianna E.: I wanted to get an opinion on the documentation of admission and discharge dates on a discharge summary when the patient starts his/her stay in the ED, then to observation status, then to IP status. What should the actual admit date be: the ED date, the OBS date, or the IP date? Thank you.

Answer from OHIMA: Hospital admission begins with a physician's order to admit.  So if the patient is in the ED at 11:00 p.m. on the 29th and is not admitted until 3:15 a.m. the next day (the 30th), the admit date is the 30th.  The same would be true if there was an observation status in-between, the admit isn't until the admit order is written, signed, and dated. 

Now the part that muddies this is that Medicare has the "three-day window" where outpatient services related to the admission are included on the inpatient stay.  So the ED and observation charges will end up on that admit.

Information related to this can be found in the Medicare Claims Processing Manual and on the CMS website at: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Three_Day_Payment_Window

Do you have a question??  Ask an HIM expert!  We will do our best to answer questions on any topic ranging from HIM, management, beginning your HIM career, CEUs, OHIMA, AHIMA, etc.!  Submit your question HERE.

EVALI

The newest health crisis is lung injury associated with e-cigarettes or vaping.  This “In the kNOW” article will explore advice for proper coding for this condition.

In October, the Centers for Disease Control (CDC) published supplemental guidance on coding for e-cigarette or vaping associated lung injury (EVALI).  This guidance was approved by the four Co-Operating Parties so it is official coding guidance and should be used when coding for EVALI.  Let’s look at this advice in more detail.

First, what is vaping?  Vaping occurs when a person (vaper) uses an e-cigarette or other electronic device to create and inhale vapor.  Most of these products contain nicotine.  However, even if nicotine is not used in the product, other chemicals that can cause lung irritation are.  Hence, the reason there are an increasing number of patients who are suffering with lung injury as a result of vaping.
The newly issued coding guidance explains that the information provided is based on the ICD-10-CM codes for 2020 and that the guidance will be updated as new clinical information becomes available.  Consideration for new codes related to this condition will be reviewed at a future Coordination and Maintenance Committee meeting.

The coding guidance indicates that coding professionals should assign the code for the specific condition if it is documented, such as J68.0, Bronchitis and pneumonitis due to chemicals, gases, fumes and vapors; includes chemical pneumonitis.  If there is an acute lung injury without further specificity assign J68.9, Unspecified respiratory condition due to chemicals, gases, fumes, and vapors.

E-cigarette liquid, which contains nicotine, can lead to poisoning if the liquid is swallowed or absorbed through the skin.  When coding for this condition assign T65.291-, Toxic effect of other nicotine and tobacco, accidental (unintentional); includes Toxic effect of other tobacco and nicotine NOS.  Some patients use these e-cigarettes to vape tetrahydrocannabinol (THC).  If toxicity is the result of this usage, assign T40.7X1- Poisoning by cannabis (derivatives), accidental (unintentional).

If substance use/abuse/dependence are documented for the condition, an additional code should be assigned to capture that information as well.  For example, vaping of nicotine would be coded as F17.29- Nicotine dependence, other tobacco products. Electronic nicotine delivery systems (ENDS) are non-combustible tobacco products.

Keep in mind that if only symptoms are documented without a definitive diagnosis being identified, coding professionals should assign the code(s) for the symptoms such as R06.02 for shortness of breath, or R06.2 for wheezing.

The CDC guidance can be found in its entirety at https://www.cdc.gov/nchs/data/icd/Vapingcodingguidance2019_10_17_2019.pdf

Now you are In the kNOW!!

About the Author 

Dianna Foley, RHIA, CHPS, CCS  is OHIMA's Coding Education Coordinator. Dianna has been an HIM professional for 20 years. She progressed through the ranks of coder, department supervisor, and department director, to her current role as a coding consultant. 

She recently served as the program director for Medical Coding and HIT at Eastern Gateway Community College. Dianna earned her bachelor's degree from the University of Cincinnati subsequently achieving her RHIA, CHPS, and CCS certifications. She is an AHIMA Approved ICD-10-CM/PCS Trainer and a a presenter at regional HIM meetings and the OHIMA Annual Meeting.