Coding corner: properly documenting asthma and chronic obstructive pulmonary disease

Asthma and chronic obstructive pulmonary disease are chronic, inflammatory airway obstructions that share similar symptoms, including shortness of breath, coughing and wheezing. These similarities can make it difficult to distinguish one condition from the other without concise documentation.

Complete and accurate documentation, to the greatest specificity possible, can play a crucial role in the continuum of care and appropriate reimbursement. It’s important to be specific when documenting current medical issues and to be clear if a condition still exists. Using the term “history of” can lead to the assumption that the condition no longer exists and is resolved.

When a patient who has asthma or COPD seeks medical attention for an acute condition, such as a sore throat or cough, it’s important that the physician documents their chronic conditions as well as their current status. This is important from a coding perspective as the documentation has an impact on the ICD-9-CM codes chosen by the coder.

Following is information that may be useful in properly coding these two conditions.

Asthma
Asthma is a chronic or long-term lung disease that inflames and narrows the airways. Codes for asthma fall under ICD-9 category 493 and the fourth and fifth digits are required for all codes in this category. The table on the right provides more detail for the codes in this category. Note that the fifth-digit sub-classifications don’t apply to 493.8, which have their own fifth-digit descriptions: 493.81 – exercise induced asthma, and 493.82 – cough variant asthma.

COPD
COPD is an umbrella term for a broad classification of disorders characterized by airway obstruction and airflow limitations.

Diseases that fall under the COPD classification include emphysema, chronic bronchitis and bronchiectasis. With COPD, the air sacs are permanently damaged, making it harder to move air in and out of the lungs.

Because of the wide range of ICD-9-CM codes, specific documentation from the physician assists the coder in selecting a code with the highest level of specificity.

Physician documentation makes a difference. For example, if documentation states “asthma,” the coder would select 493.90 (asthma, unspecified), while documentation of “intrinsic asthma” would be coded to 493.10 (intrinsic asthma, unspecified).

Documentation of “COPD” uses the code 496 (COPD, unspecified), while documentation of “exacerbation of COPD” uses code 491.21 (obstructive chronic bronchitis, with acute exacerbation). The fifth digit of an ICD-9-CM code is used to capture the specificity of the diagnosis, such as “unspecified, with or without exacerbations,” or “with or without status asthmaticus.”

Examples to substantiate validations in the medical record for asthma or COPD include:

• Medication given for the condition
• Pulmonary function testing
• Documentation of oxygen saturation (normal range 95 to 100 percent)
• Occupational exposure to dusts and chemicals
• Genetics

As you evaluate patients for asthma and COPD, this information is intended to help you understand the importance of documenting the diagnosis to the highest specificity. From a coding perspective, the medical record coder must be able to validate the condition documented by the physician.

None of the information included in this article is intended to be legal advice and, as such, it remains the provider’s responsibility to ensure that all coding and documentation are done in accordance with applicable state and federal laws and regulations.