Health Information Management

Review new asthma terminology in ICD-10-CM

JustCoding News: Inpatient, October 24, 2012

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Intrinsic. Extrinsic. Chronic obstructive.

These are just some of the terms in ICD-9-CM code category 493.xx that describe asthma—a chronic lung disease that causes the lung airways to swell and narrow.

ICD-10-CM code category J45.- includes new, more specific terms that may help improve data quality and lead to more effective research and treatments.

In particular, J45.- denotes severity and frequency (i.e., mild intermittent, mild persistent, moderate persistent, severe persistent) and the presence of status asthmaticus or acute exacerbation. These details are necessary for a complete ICD-10 code.

What coders need to know
Specificity is paramount, says Deborah Grider, CPC, CPC-I, CPC-H, CPC-P, CPMA, CEMC, CPCD, COBGC, CCS-P CDIP, an AHIMA-approved ICD-10 trainer and senior manager at Blue & Company in Indianapolis. Grider performs chart reviews and ICD-10 readiness assessments for hospitals and physician practices nationwide. She says asthma documentation needs improvement across the board. Hospitals often default to code 493.9 (asthma, unspecified). Providers must document greater specificity to avoid doing so with ICD-10 as well, she says.

“If [the asthma] isn't going to impact the DRG, coders typically default to the unspecified code,” says Grider. “But it's not correct, and the name of the game with ICD-10 is specificity.”

Suzan Berman, CPC, CEMC, CEDC, senior director of physician services at Health Revenue Assurance Associates in Plantation, Fla., agrees. “We can only assume that because there's greater specificity available, the insurance companies are going to want greater specificity,” she says.

For example, physicians should avoid documenting “chronic asthma,” says Berman. Coders currently report ICD-9-CM code 493.2x to denote chronic asthma or chronic obstructive pulmonary disease (COPD), but this condition maps to an unspecified code (J44.9) in ICD-10-CM.

“We’re trying to teach the physicians to steer clear of unspecified codes,” says Berman. Not teaching physicians what’s needed from a documentation specificity perspective and reporting the unspecified code instead would be “detrimental to the revenue cycle,” she says.

Sequencing is also important. “If you make physicians more aware of the details [in ICD-10], they may end up telling you that the patient really doesn’t have chronic asthma or COPD—they have an acute exacerbation of mild persistent asthma associated with COPD, in which case coders should report J45.31 followed by J44.9,” says Berman. The acute exacerbation—not COPD—is typically the reason for admission. Sequencing codes this way can help reduce denials for medical necessity, she says.
If patients have COPD and asthma, coders must assign two codes (from category J44 for COPD and category J45 to identify the severity and status of the asthma), according to the ICD-10-CM Official Guidelines for Coding and Reporting.

ICD-10-CM codes for asthma also reference Excludes notes. For example, Excludes1 notes (i.e., two codes may not be reported together) applies to miner’s asthma (an acquired form of asthma) and mild intermittent asthma (a congenital form of asthma). Excludes2 notes (i.e., the code for the condition and the excluded code may be reported together) applies to patients with an acute exacerbation of mild persistent asthma and chronic obstructive asthma.

The ICD-10-CM Official Guidelines for Coding and Reporting define an acute exacerbation as “a worsening or a decompensation of a chronic condition.” They also state that “an acute exacerbation is not equivalent to an infection superimposed on a chronic condition, though an exacerbation may be triggered by an infection.”

Coders should remember present on admission (POA) guidelines. Assign “N” if any part of the condition denoted by a combination code was not POA (e.g., patient with asthma develops status asthmaticus after admission).

When reporting an ICD-10-CM category J45.- code, use additional codes to specify the following:

  • Exposure to environmental tobacco smoke (Z77.22)
  • Exposure to tobacco smoke in the perinatal period (P96.81)
  • History of tobacco use (Z87.891)
  • Occupational exposure to environmental tobacco smoke (Z57.31)
  • Tobacco dependence (F17-)
  • Tobacco use (Z72.0)

Communication with physicians
Physicians must understand that the terminology has been expanded, says Berman. Asking simple questions such as, “Do you use chronic asthma and persistent asthma synonymously, or are they separate diagnoses in your mind?” is helpful, she says.

It’s not too soon to discuss documentation specificity, says Grider. Benefits include fewer queries and justification of medical necessity, she says.

Inquire about clinical criteria and clinical indicators for each type of asthma, says Grider, who expressed hope that Coding Clinic will develop guidance.

Develop internal guidelines and coding tip sheets based on information from credible sources (e.g., the American College of Chest Physicians or the National Heart, Lung, and Blood Institute [NHLBI]). The National Asthma Education and Prevention Program Coordinating Committee, coordinated by the NHLBI of the National Institutes of Health, offers diagnosis and management guidelines.

Consider CMS and contractor policies when determining whether a documented diagnosis matches the clinical treatment and picture. “Policies are very specific, especially in pulmonology, in terms of what is considered clinically relevant for a condition,” says Grider.

Editor's note: This article originally appeared in the October issue of Briefings on Coding Compliance Strategies. Email your questions to Senior Managing Editor Michelle A. Leppert, CPC, at mleppert@hcpro.com.



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