Coding to New Heights Education Newsletter March 2019 Edition

Peak Health Solutions - Mar 15, 2019


Welcome to our Monthly Peak Coding Education Newsletter, March 2019 Edition! This month we'll discuss:
Asthma for ICD-10-CM, Endobronchial Brachytherapy for ICD-10-PCS, Understanding Bronchoscopy Procedures for CPT, Outline COPD for Pro-Fee, Discuss Lobes of the Lung in our Anatomy Feature, Corner Respiratory Failure Clinical Indicators in our CDI Corner, Inhalers in our Pharmacology Spotlight and test your knowledge with a Code Puzzler that might take your breath away!

In This Issue

funny-documentation-fail-125X125-BFunny Documentation Fail

“Patient had a grandma seizure"




Submitted by Dee Mandley, RHIT,
Lead Educator

Asthma is a very common illness affecting 3 million people each year. This chronic condition occurs in the bronchioles of the lungs causing the muscles around the airways to become tight and the airway lining to swell. Irritants such as pet dander, cigarette smoke, pollution and dust can cause people with asthma to have an attack. When this occurs the amount of air allowed to pass through the bronchioles is reduced leading to wheezing, shortness of breath, chest tightness, and coughing. Most people are symptom free between attacks while others deal with long-term shortness of breath.

ICD-10-CM requires much detail to properly code asthma. This detail involves identifying the type which is easier said than done. There are many types of asthma and diagnosing the type can be difficult unless the patient takes good notes on when and what triggered their attacks. There’s allergic, nighttime, cough-variant, occupational, and exercise-induced to name a few. The cause of these types is pretty obvious by their names but cough-variant is vastly underdosed and undertreated. Cough-variant, so named because of severe coughing spells is caused by post-nasal drip, chronic rhinitis, sinusitis or GERD (gastroesophageal reflux).

Once the first hurdle of identifying the type has been determined it is time to seek the next level of detail required by ICD-10-CM. Identifying whether the patient’s asthma is intermittent, mild persistent, moderate persistent and severe persistent. These categories are based on symptoms and frequency of attacks. Intermittent asthma, coded to the J45.2x category, classifies attacks as occurring fewer than two days a week not interfering with activities of daily living. Mild persistent asthma, coded to the J45.3x category, classifies attacks as occurring on two non-consecutive days a week interfering with daily activities. Patients with moderate persistent, coded to J45.4x category, or severe persistent, coded to J45.5x category, are symptomatic every day requiring daily use of an inhaler. One of the differences between moderate and severe persistent asthma is the occurrence of nighttimeattacks. In severe persistent asthma attacks can happen every night.

Other nuggets of knowledge to consider in ICD-10-CM is classifying whether status asthmaticus is present or not. In the paragraph above asthma categories are identified. Now we solve for “X”. The fourth and final digit in coding asthma supplies information of acute exacerbation or status asthmaticus. What’s the difference you ask? Status asthmaticus is an acute exacerbation that remains unresponsive to initial treatment with bronchodilators. In its most severe form status asthmaticus is characterized with bronchospasm, airway inflammation, mucus plugging, carbon dioxide retention, hypoxemia, and respiratory failure.

Clinical indicator alert: documentation of status asthmaticus may be written with words such as intractable,refractory, severe intractable wheezing, airway obstruction not relieved by bronchodilators, or severe prolonged asthmatic attack. If any of these phrases are in the chart and status asthmaticus is in question query the provider.

Because ICD-10-CM has a code for each of these complications it leads this coder to ask “What if both are present and documented in the record?” The Faye Brown Coding Handbook states that when both acute exacerbation and status asthmaticus are documented to code only asthma with status asthmaticus the fourth and final character of 2.


Endobronchial Brachytherapy

Submitted by Dee Mandley, RHIT, CCS, CCS-P, CDIP 
Lead Educator

Endobronchial brachytherapy is typically done on nonresectable endobronchial tumors. Brachytherapy is done along with external-beam radiation as this technique minimizes radiation exposure to healthy tissue. The radiation oncologist will develop a treatment plan based on location, size, and stage of cancer and decide to use high dose or low dose radiation. Brachytherapy on the lung is performed on obstructing tumors through a flexible fiberoptic bronchoscope. Once the tumor is visualized and photographed for later comparison, a catheter tip is placed distal to the tumor. Bronchoscope is withdrawn and reinserted through the other nostril to verify location. Multiple catheters may be placed depending on the amount of obstruction and size of tumor. Fluoroscopy is used to make sure the catheter tip stays in place as the bronchoscope is removed. The catheter is taped to the nose and the patient is taken to radiation therapy. The catheter is removed once treatment is complete.Endobronchial-Brachytherapy-300-wide

When assigning an ICD-10-PCS code the coder must determine the treatment site, high or low dose rate brachytherapy, and type of isotope. Types of isotopes identified in ICD-10-PCS are: Californium 252 (Cf-252); Cesium 137 Cs-137); Iodine 125(I-125); Iridium 192(Ir-192); Palladium 103(Pd-103). Surgical approach is via natural or artificial opening endoscopic. A second code is assigned to identify the final location of brachytherapy. The first level character is section “D” Radiation Therapy. The body system “B” respiratory therapy leads to the operation value of “1” for brachytherapy. From there the treatment site is chosen and the modality qualifier of high dose vs low dose is chosen and finally the specific name of the isotope.

Example Codes:
DB1199Z High Dose Rate (HDR) Brachytherapy of Bronchus using Iodine 125 (I-125)
0BH081Z Insertion of Radioactive Element into Tracheobronchial Tree, via Natural or Artificial Opening Endoscopic



Understanding Bronchoscopy Procedures

Submitted by Peggy Hapner, RHIA, CCS, CASCC 

Bronchoscopy procedures involve using an endoscope to perform a diagnostic or therapeutic visualization of the patient’s airways. During this procedure a scope is inserted either through the mouth or nose and proceeds through the throat into the bronchi and lungs. In this article we are going to discuss several different procedures that can be performed via the bronchoscope. Bronchoscopy procedures are assigned to CPT codes 31622-31661.

First, we need to discuss the different types of bronchoscopies:

Flexible Bronchoscopy – the more common of the bronchoscopes used today, uses a standard white light source with flexible equipment that allows the physician to flex or extend the scope to better visualize the bronchi and lungs. This procedure is usually performed under conscious sedation however general sedation may also be used.
Rigid Bronchoscopy – also uses a white light source, however, the equipment is more rigid as it uses a less flexible metal tube to perform the scope. This procedure requires general anesthesia to be performed.

Virtual Bronchoscopy – unlike the Flexible or Rigid Bronchoscopes this procedure does not use an endoscope. It is an imaging procedure that utilizes 3-dimentional techniques that provides images similar to what a physician would see during a Flexible or Rigid Bronchoscope. Less used as facilities would need the equipment and expertise to perform Virtual Bronchoscopy.

Next let us look at a couple of procedures that can be performed in conjunction with a Flexible Bronchoscope. The first one being endobronchial ultrasound – which is a flexible scope with the addition of an ultrasound probe placed at the distal end of the scope. The endobronchial ultrasound provides a way for the physician to visualize surrounding tissue and structures (i.e., lymph nodes, blood vessels, tumors/masses). The second procedure that a coder may see in conjunction with a flexible scope is Navigational Bronchoscopy. In this procedure electromagnetic or virtual navigation maybe performed to either better reach distal areas or better visualize the areas that a normal scope cannot reach.
Let’s explore some of the different accessory procedures that can be performed for a diagnostic or therapeutic flexible or rigid bronchoscopy.

Cell Washing - utilizes a small amount of saline over a specified area to collect cells from the area for cytological examination. Part of the diagnostic bronchoscopy.
Brushings or Protected Brushings – a brush is negotiated through the bronchoscope to the desired location to obtain a specimen. The catheter protects the brush to avoid any contamination of the specimen.

Bronchial Alveolar Lavage – involves using a large amount of saline being infused and the saline then suctioned out to retrieve cells. Typically, the lavage could possibly be performed multiple times to ensure cells are retrieved.
Endobronchial Biopsy – bronchial biopsies are performed. The biopsy could be performed on a single or multiple sites.

Transbronchial Biopsy - in this procedure the physician punctures a hole in the bronchiole with biopsy forceps to retrieve lung tissue. It is important to see in the documentation that the physician documented transbronchial biopsy as the pathology report is unreliable in providing this information.

Transbronchial Needle Aspiration – aspiration biopsy of lung tissue through the hole in the bronchiole with a needle. Again, be sure that the physician states transbronchial needle aspiration. The physician often calls this a WANG needle aspiration.

There are several of procedures that are listed in the CPT Code book that can be performed either through a flexible or rigid bronchoscope. Above are the most common procedures that a coder might encounter in the hospital outpatient setting.

Bronchoscopy coding tips:

It is key that the coder understands the anatomy of the respiratory system to aid in the appropriate code selection.

Be sure to ready the coding description carefully to determine if the procedure documentation supports the code assignment.

A surgical bronchoscopy includes a diagnostic bronchoscopy when performed by the same physician.

Code the appropriate endoscopy of each anatomical site examined. A physician may state “panendoscopy” procedure which includes an esophagoscopy, laryngoscopy and bronchoscopy all performed in one setting. Code each one out separately and then follow the coding edits.

Modifier usage – It is appropriate to report LE and RT if a procedure is performed on one side or modifier 50 if a bilateral procedure. This is correct per coding rules however Medicare does not recognize modifier 50 for bilateral procedure for reimbursement as they consider many of these procedures inherently bilateral.

If in doubt of the documentation it is important to discuss any questions or concerns with the physician performing the bronchoscopy.


E/M ProFeeWhat-is-COPD-400-wide

What is COPD?

Submitted by Heather Saunders, CPC, CEDC, CEMC, CHCAS, CHCA
Pro-Fee Lead Auditor

COPD is an abbreviation for Chronic Obstructive Pulmonary Disease which makes it hard to breathe.

Within the lungs, your bronchial tubes branch many times into thousands of smaller, thinner tubes called bronchioles. These tubes end in bunches of tiny round air sacs called alveoli.

Small blood vessels called capillaries run along the walls of the air sacs. When air reaches the air sacs, oxygen passes through the air sac walls into the blood in the capillaries. At the same time, a waste product, called carbon dioxide (CO2) gas, moves from the capillaries into the air sacs. This process, called gas exchange, brings in oxygen for the body to use for vital functions and removes the CO2.

The airways and air sacs are elastic or stretchy. When you breathe in, each air sac fills up with air, like a small balloon. When you breathe out, the air sacs deflate and the air goes out.

In COPD, less air flows in and out of the airways because of one or more of the following:

  • The airways and air sacs lose their elastic quality.
  • The walls between many of the air sacs are destroyed.
  • The walls of the airways become thick and inflamed.
  • The airways make more mucus than usual and can become clogged.

COPD includes two main conditions – emphysema and chronic bronchitis.

In emphysema, the walls between many of the air sacs are damaged. As a result, the air sacs lose their shape and become floppy. This damage also can destroy the walls of the air sacs, leading to fewer and larger air sacs instead of many tiny ones. If this happens, the amount of gas exchange in the lungs is reduced.

In chronic bronchitis, the lining of the airways stays constantly irritated and inflamed, and this causes the lining to swell. Lots of thick mucus forms in the airways, making it hard to breathe.

Most people who have COPD have both emphysema and chronic bronchitis, but the severity of each condition varies from person to person. Thus, the general term COPD is more accurate.

Common signs and symptoms of COPD include:

  • An ongoing cough or a cough that produces a lot of mucus; this is often called smoker's cough.
  • Shortness of breath, especially with physical activity
  • Wheezing or a whistling or squeaky sound when you breathe
  • Chest tightness

In ICD-10-CM 2019 –

  • J44 – Other chronic obstructive pulmonary disease
  • Includes
    • Asthma with chronic obstructive pulmonary disease
    • Chronic asthmatic (obstructive) bronchitis
    • Chronic bronchitis with airways obstruction
    • Chronic bronchitis with emphysema
    • Chronic emphysematous bronchitis
    • Chronic obstructive asthma
    • Chronic obstructive asthma
    • Chronic obstructive bronchitis
    • Chronic obstructive tracheobronchitis
  • Code also type of asthma, if applicable (J45-)
  • Use additional code to identify –
    • Exposure to environmental tobacco smoke (Z27.22)
    • History of tobacco dependence (Z87.891)
    • Occupational exposure to environemtnal tobacco smoke (Z57.31)
    • Tobacco dependence (F17-)
    • Tobacco use (Z72.0)
  • Excludes 1
    • Bronchiectasis (J47-)
    • Chronic bronchitis NOS (J42)
    • Chronic simple and mucopurulent bronchitis (J41-)
    • Chronic tracheitis (J42)
    • Chronic tracheobronchitis (J42)
    • Emphysema without chronic bronchitis (J42)
Be sure to read the documentation carefully in order to assign the correct code. Read all of the “Includes” and “Excludes 1” information.

National Heart, Lung and Blood Institute - NIH
2019 ICD-10-CM Official Guidelines
Journal of AHIMA – Better Understanding COPD – March 15, 2018  



Anatomy Feature

Lobes of the Lung

Submitted by Dee Mandley, RHIT, CCS, CCS-P, CDIP
Lead Educator

In the anatomy feature this month I thought it might be useful to demonstrate the five lobes of the lungs. When coding neoplasms, for instance, the codes are divided by bronchus and lobes of the lungs. In the diagram above the five lobes are identified with abbreviations often used in medical record documentation. Note that there are two lobes on the left and three lobes on the right conveniently separated by fissures. The right upper lobe (RUL) and left upper lobes (LUL) may be documented in the medical record as superior lobes. The right middle lobe (RML) may be documented as simply the middle lobe. The right lower lobe (RLL) and left lower lobe (LLL) may be documented as inferior lobes. The lung’s primary purpose is gas exchange between oxygen and carbon dioxide. Interestingly enough is that the air we breathe is 21% oxygen but our body only uses 5%. The rest is exhaled! That exhale carries with it 70% waste. Let’s take a break a moment and ponder this information and take a much-needed deep breath. If you like, take a moment and try a well-known breathing exercise that is guaranteed to make you feel better. Inhale through your nose for a count of 4, hold for a count of 7, and exhale out your mouth for a count of 8.

Now that our brains have some much-needed oxygen lets discuss the pleura and bronchi. Each lung is enclosed in a sac known as the pleura. The pleura is made up of two layers and the space between those layers is known as the pleural cavity. The Bronchial tree begins with the primary bronchus and continues to divide into smaller branches known as bronchioles. The alveoli are at the ends of the “branches” and have a grape-like appearance. The walls between the alveoli and the pulmonary capillaries are extremely thin allowing for quick gas exchange of oxygen and carbon dioxide.


CDI Corner

Respiratory Failure Clinical Indicators

Submitted by Dee Mandley, RHIT, CCS, CCS-P, CDIP 
Lead Educator

When coding respiratory failure there are a few details that must be sought in the medical record documentation in order to properly assign the most specific code possible. First look for documentation of the acuity, i.e. Acute, Chronic, or Acute and Chronic. Next look for documentation of presence of hypoxemia and/or hypercapnia.

In the event of missing documentation CDI specialists must dig a lot further and look for clinical indicators that a condition is present. Acute respiratory failure is characterized by hypoxemia, a low PaO2, or hypercapnia, a high PaCO2, and acidemia, a low pH. If both hypoxemia and hypercapnia are present both should be coded. Lab work clinical indicators for acute respiratory failure with hypoxia (also known as Type 1) are pO2 < 60 mmHg (SpO2 < 90%) on room air OR pO2/FIO2 (P/F) ratio < 300 OR 10 mmHg decrease in baseline pO2. Conversely, lab work clinical indicators for acute respiratory failure with hypercapnia (also known as Type 2) pCO2 > 50 mmHg with pH <7.35 OR 10 mmHg increase in baseline pCO2. Hypercapnia occurs with acidemia denoting the change in CO2 was too extreme for renal compensation and the pH value of ≤ 7.34 will indicate if its acute or chronic. In the absence of ABG testing check for documentation of increased work of breathing.

Some other signs and symptoms of acute respiratory failure are: altered mental status, cyanosis, decreased oxygen saturation on pulse oximetry, tachycardia, hypertension, diaphoresis, accessory muscle use, nostril flaring, tachypnea, and diaphragmatic fatigue.

Chronic respiratory failure can be coded with hypoxemia and/or hypercapnia as well however, the pH value will be normal. Chronic denotes a condition that has occurred over a period of months to years and is common in patients with COPD.

Acute and chronic respiratory failure occurs in patients who already suffer from chronic respiratory failure who experience an abrupt increase in the degree of hypoxemia or hypercapnia. Respiratory infections or pneumonia can be the culprits.

Besides the obvious treatment of mechanical ventilation, look for bronchodilator medications given orally or by infusion and inhalation treatments such as Albuterol.



Pharmacology Spotlight


Submitted by Dee Mandley, RHIT, CCS, CCS-P, CDIP 
Lead Educator

Used to treat mainly Asthma and COPD, inhalers come in all shapes and sizes and contain different types and combinations of drugs. These handheld devices deliver a puff of medicine in liquid, powder, or soft mist form. The types of medications used in inhalers are antibiotics to treat secondary infections, corticosteroids to reduce inflammation, bronchodilators to dilate the airways, and Phosphdiesterase-4 (PDE4) Inhibitors to inhibit inflammation and relax airway smooth muscle.

Common inhalers on the market

  • Advair® is a combination of corticosteroid and bronchodilator used for COPD management.
  • Symbicort® is a combination of corticosteroid and bronchodilator used for treatment of asthma and stable COPD
  • Combivent Respimat® contains two bronchodilators
  • Pulmicort® contains a corticosteroid for COPD management
  • Spiriva® contains a bronchodilator for COPD management
  • Proventil® is a rescue inhaler containing a bronchodilator used to control bronchospasm events in asthma and COPD
  • Atrovent® contains a bronchodilator for COPD management
  • Brovana® contains a bronchodilator for COPD management and is not used to treat asthma
  • Arcapta Neohaler® contains a dry powder bronchodilator used in maintenance of COPD, emphysema, and chronic bronchitis
  • Breo Ellipta® contains corticosteroid and log-acting beta2-adrenergic agonist used in maintenance of COPD, emphysema, and chronic bronchitis
  • Trelegy Ellipta® the first and only inhaler with three medications-a corticosteroid, long-acting muscarinic antagonist and a long-acting beta2-adrenergic agonist used to treat asthma


The Code Puzzler

This month’s puzzler comes from Sarah McDougal, Coding Auditor

Here’s the scenario – as it appeared in the record. Good Luck!

On admission:

85-year-old female presented to the ER by EMS for respiratory distress. Per EMS sat 84% when they arrived; placed on BiPAP. Patient was noted to be in VT. Bolus of amiodarone given. Patient converted to A Fib. Patient placed on amiodarone drip. BNP 473, tolerating BiPAP well. Patient states she does not want to be intubated.

Admitting diagnoses: Acute on chronic respiratory failure, COPD, acute on chronic diastolic CHF exacerbation, DMII.

Discharge Note:
The patient arrives to the hospital short of breath and volume overload there was possibly some concern about V tach in the ER but was most likely A Fib with RVR she required continuous BiPAP for about 10 hours and then was able to transition off. She will likely require ventilation support at night she uses home O2 at home already for her chronic respiratory failure and COPD stable for discharge home today on home medications there is no evidence of infection.

Assessment and Plan:

  • Acute on Chronic Respiratory Failure – IV Lasix, monitor I and O, RT eval and treat, BiPAP, continue home medications, ICU monitoring
  • Acute on Chronic Diastolic CHF – IV Lasix, I and O’s, continue home medications
  • HX of cardiac arrythmia (VT in ER, chronic a fib); amiodarone gtt, ICU monitoring, continue home meds as tolerated
  • DM2 – medium sliding scale insulin ac and hs, continue home meds, 1800 cal diet when tolerating being off BiPAP
  • Benign essential hypertension: continue home medications, monitor
  • DVT prop- scd, Plavix, asa
  • GI prop-protonix QD
  • Patient requests to be DNI, no written advanced directives, daughter is POC

Assign the codes for this case.

ANSWER:  Highlight the text below to see if you were correct!
I11.0 Hypertensive heart disease with heart failure
J96.21 Acute and chronic respiratory failure with hypoxia
I50.33 Acute on chronic diastolic (congestive) heart failure
E11.9 Type 2 diabetes mellitus without complications
I48.2 Chronic atrial fibrillation
J44.9 Chronic obstructive pulmonary disease, unspecified
Z79.82 Long term current use of aspirin
Z79.01 Long term current use of anticoagulants
Z99.81 Dependence on supplemental oxygen


Documentation noted on Discharge Summary pg. 1 and H&P pg. 1 states the patient was in acute on chronic diastolic CHF and acute on chronic respiratory failure. The patient had shortness of breath and volume overload on admission. Recommend sequencing I110 (Hypertensive heart disease with heart failure) as principal diagnosis per OCG, Section II, Selection of Principal Diagnosis and per coding guidance noted in AHA Coding Handbook which notes "respiratory failure is always due to an underlying condition." The patient was placed on IV Lasix and monitor I and O's throughout stay.

Recommend sequencing J9621 (Acute and chronic respiratory failure with hypoxia) as secondary diagnosis per OCG, Section III, reporting additional diagnosis coding guidelines and per AHA CC guidance noted in Ch. 19 Diseases of the Respiratory System, Respiratory Failure, notes respiratory failure is always due to an underlying condition. 

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