Procedure Practice 03/15/99 - Coding Recommendations

Feature Article 03/15/99

Common Lung Diseases and Disorders

Anatomy - Respiratory Diseases and Disorders
Diagnostic Tests - Surgical Procedures - Coding Tips and Guidelines

Lung disease is the number three killer in America, responsible for one in seven deaths. More than 30 million Americans are living with chronic lung diseases such as asthma, emphysema, or chronic bronchitis. Acute pulmonary infections are responsible for innumerable office visits and hospital admissions each year. This month, we review pulmonary anatomy, discuss some common lung diagnoses, pulmonary tests, and surgical procedures and review coding guidelines specific to respiratory disorders.
  

Anatomy

Trachea, Bronchi, and Bronchioles

The upper structures of the respiratory system are combined with the sensory organs of smell and taste in the nasal cavity and mouth and the digestive system from the oral cavity to the pharynx. At the pharynx, the specialized respiratory organs diverge into the trachea. The trachea lies anterior to the esophagus. The right and left main bronchi branch off the bifurcation at the lower end of the trachea to enter the hilus of the left or right lung. The carina is the keel-shaped cartilage lying within the tracheal bifurcation. The main bronchi branch off into upper, middle, and lower lobes. These lobes continue to branch into smaller and smaller passageways called bronchioles, forming a tree-like network which extends throughout the spongy lung tissues. The exterior of the bronchi is composed of elastic cartilaginous fibers with annular reinforcements of smooth muscle that allow the bronchi to expand and contract .
  

Lungs

Both lungs feature fissures that divide the overall structures into smaller lobes. The left lung has one horizontal fissure which divides it into two lobes (upper and lower). The right lung has one horizontal fissure and one oblique fissure, dividing it into three lobes (upper, middle, and lower). It is larger than the left, extending further down in the abdominal cavity. The entire pleural cavity is enclosed by a serous membrane called the parietal pleura. Each lung is surrounded by the visceral pleura. The pleural membranes provide lubrication for the lungs as they expand and contract. The lungs are separated by the mediastinum, a membrane that extends from the vertebral column in back to the sternum in front.
   

Alveoli and Capillary Network

The alveoli are the functional units within the lungs where gas exchange occurs. Each bronchiole divides into multiple narrow inlets called alveolar ducts. The ducts in turn subdivide and lead into three or more alveolar sacs. Each large alveolar sac is like a grape cluster composed of ten or more alveoli.

Two types of cells line the alveoli. Most are flat squamous cells. A few are larger and secrete a lipid material called surfectant. The function of surfectant is to lower the surface tension of the molecules within the fluid lining the alveoli, thereby facilitating respiration.

The capillary network within the alveolar tissue allows transmission of gases between the air in the alveoli and the blood cells within the capillaries. The tiny capillaries allow blood cells to pass through them one at a time. This single-file order and the delicate, semipermeable nature of the membrane separating the alveolar sacs from the capillaries allows the exchange of oxygen and carbon dioxide. The blood cells passing through the capillaries are depleted of oxygen and rich in carbon dioxide and other waste gases. As a result, the carbon dioxide passes through the membrane to the air within the alveoli, which is less rich in carbon dioxide. Similarly, the oxygen within the alveoli passes through the membrane to the blood cells. In this way, the blood gets rid of excess carbon dioxide (which is subsequently exhaled) and is regenerated by oxygen. The regenerated blood cells continue on through the pulmonary vein to the heart from which it is pumped to the rest of the body.
   

Diaphragm and Ribs

The diaphragm is the largest muscle of respiration, and it is situated just below the lungs. Working with the intercostal and abdominal muscles, the diaphragm contracts and expands the thoracic cavity to effect respiration. The rib cage serves as a structural support for the whole thoracic cavity.
  

Respiratory Diseases and Disorders

COPD

Chronic obstructive pulmonary disease (COPD) includes emphysema and chronic bronchitis. Both diseases are characterized by obstruction to airflow. Emphysema and chronic bronchitis frequently coexist, thus physicians prefer the term COPD. Nearly 16 million Americans suffer from COPD, which is the fourth leading cause of death. The annual cost to the nation for COPD is approximately $31.9 billion. Approximately 80 to 90 percent of COPD cases are caused by smoking. Other known causes are frequent lung infections and exposure to certain industrial pollutants.

• Emphysema is a condition in which the alveoli become damaged and over-inflated. Alveoli walls are thin and fragile. Damage to the walls is irreversible and results in permanent "holes" in the tissues of the lower lungs. As the alveoli are destroyed, the lungs’ ability to transfer oxygen to the bloodstream becomes increasingly impaired, causing shortness of breath or "air hunger." The lungs also lose their elasticity, making it difficult not only to inhale efficiently, but also to exhale carbon dioxide. The bronchioles leading to the alveoli may collapse and trap air in the lungs. This is the condition known as emphysema.
    
• A1AD (Alpha-1-antitrypsin deficiency) related emphysema is caused by an inherited lack of a protective protein called alpha-1-antitrypsin (AAT). In healthy individuals, AAT, which is produced in the liver, neutralizes an enzyme called neutrophil elastase. Neutrophil elastase is released by the white blood cells during times of inflammation. This action is normally helpful and is balanced by the presence of AAT. In people without protective AAT (either because the liver does not produce adequate amounts or cannot release it into the bloodstream), the neutrophil elastase attacks the walls of the alveoli, causing irreversible damage. If untreated, A1AD emphysema is progressive and often fatal. The first signs of A1AD related emphysema often appear between ages 30 and 40. Both the early age at which the disease is present and the fact that the disease most frequently appears in the lower rather than the upper lung regions help distinguish A1AD related emphysema from other types of emphysema.
    
• Chronic bronchitis is an inflammation of the bronchial lining. When the bronchi are inflamed and/or infected, less air flows to and from the lungs. Chronic bronchitis is defined by the presence of a mucus-producing cough for three months or more for two successive years without other underlying disease to explain the cough. It may precede or accompany pulmonary emphysema. Cigarette smoking is the most common cause of chronic bronchitis. Air pollution and industrial dusts and fumes also contribute to chronic bronchitis. Once the bronchi have been irritated over a long period of time, excessive mucus is produced constantly, the lining of the bronchi becomes thickened, a chronic cough develops, airflow is hampered, and the lungs are endangered. The bronchi then make an ideal breeding place for infections.
     

Asthma/Reactive Airways Disease

About 3% of Americans have asthma. Asthma is common in adults and even more common among children. The American Thoracic Society defines asthma as a "disease characterized by an increased responsiveness of the trachea and bronchi to various stimuli … manifested by widespread narrowing of the airways that changes in severity either spontaneously or as a result of treatment." Asthma is characterized by hypertrophy of the bronchial smooth muscle, mucosal edema and hyperemia, acute inflammation, and plugging of the airways by thick mucus. These changes result in varying degrees of obstruction of all airways.

The pathogenesis of asthma is poorly understood. Most researchers believe that allergic response plays a key role in the origins of the disease and that the reversible episodes of obstructed airflow are triggered by multiple complex mechanisms.
   

Pneumothorax

Pneumothorax is the accumulation of air within the pleural cavity. It may occur spontaneously or as the result of trauma. Normal intrapleural air pressure is lower than the pressure inside the lungs. This lower pressure enables the lungs to expand during inspiration. If the lung is punctured, air from the lung will flow out into the pleural cavity, thus deflating the lung and making it nonfunctional. If the chest wall is punctured and atmospheric air enters the pleural space, again the lung will collapse as the intrapleural pressure rises.

The development of a positive (higher than atmospheric) pressure in the pleural cavity, called tension pneumothorax, may accompany any type of pneumothorax. This dangerous complication occurs if the lung is perforated in such a way that the pleural tear acts as a one-way valve. In this situation, air flows through the perforation into the pleural cavity as the pleural pressure falls on inspiration. On expiration, however, the intrapleural pressure rises and forces the edges of the pleural tear together, trapping the air within the pleural space. With each inspiration, more air enters the pleural cavity but cannot escape. As the pressure builds in the pleural cavity, the affected lung completely collapses and the heart and mediastinum are displaced, encroaching on the opposite pleural cavity and impairing expansion of the opposite lung.
   

Atelectasis

Atelectasis refers to collapse of part of the lung.

• Obstructive atelectasis is caused by bronchial obstruction such as a tumor, mucus plug, or aspirated foreign body.
    
• Postoperative atelectasis is a form of obstructive atelectasis that occurs when a patient cannot cough or breathe deeply enough to clear respiratory secretions. The secretions accumulate in the bronchi and prevent adequate lung expansion. Once secretions are cleared, the lung reexpands completely.
    
• Compression atelectasis is due to external compression of the lung. The compression may be caused by the presence of blood, fluid, or air within the pleural cavity.
    

Bronchiectasis

Bronchiectasis may be either a congenital or acquired disorder of the large bronchi characterized by abnormal dilation and destruction of the bronchial walls. It is caused by recurrent infection and inflammation and is primarily a disorder of childhood and adolescence. Cystic fibrosis causes about 50% of all cases of bronchiectasis.
  

Bronchiolitis

This disease is an acute, often severe respiratory illness of infants and young children under two years old. Respiratory syncytial virus (RSV) usually causes bronchiolitis, though other viruses and occasionally mycoplasma pneumoniae are also sometimes responsible. Bronchiolitis is usually a self-limited illness, but occasionally repeated infections lead to bronchiolitis obliterans, obstruction of the bronchioles by granulation (scar) tissue. The consequences of this condition include dyspnea, obstructive lung disease, atelectasis, and bronchiectasis.
  

Bronchiolitis Obliterans with Organizing Pneumonia (BOOP)

This idiopathic disorder affects men and woman equally, with most patients between the ages of 50 and 70. In approximately one-third of all cases, the illness is preceded by a flulike upper respiratory infection, although the precise pathogenesis of BOOP is unknown. The disease is sometimes associated with connective tissue disorders, cocaine use, HIV infection, myelodysplastic syndrome, and adenovirus.

BOOP is characterized by granulation tissue plugs within the lumens of small airways. This abnormal tissue extends into alveolar ducts and alveoli. Additional pathologic features include proliferation of connective tissue that forms intramural polyps (proliferative bronchiolitis obliterans), fibrinous exudates, and inflamed alveolar walls.
  

Pneumonia

Pneumonia is an inflammation of the lung characterized by the same type of vascular changes and fluid exudate as inflammation in other areas of the body. However, the process is influenced by the spongy texture of the lung tissue. The inflammatory exudate spreads unimpeded throughout the lung, filling the alveoli, and the involved portions of lung become relatively solid (consolidation). Pneumonia is classified in several ways:

1. Etiology - This classification is the most important because it determines treatment. Bacteria, viruses, or fungi may cause pneumonia. Identifying the exact organism responsible for the disease is the key to treating the pneumonia with effective antibiotics. Examples of organisms responsible for pneumonia are pneumococcus, staphylococcus, Legionella pneumophila, and pneumocystis carinii.
     
2. Anatomic distribution of inflammation - This classification describes whether an entire lobe of the lung is involved (lobar pneumonia), or if inflammation involves only those parts of the lung closest to the bronchi (bronchopneumonia).
     
3. Predisposing factors - Any condition associated with poor lung ventilation and retention of secretions predisposes an individual to pneumonia.

• Postoperative pneumonia develops in postsurgical patients who cannot cough or breathe deeply because of pain.
• Aspiration pneumonia occurs when a foreign body such as food, liquid, or vomitus is aspirated into the lungs.
• Obstructive pneumonia occurs in the lung distal to an area where a bronchus is narrowed or obstructed. Blockage of a bronchus by a tumor or foreign body results in poor aeration and retention of secretions in the obstructed portion of the lung.
    

Pulmonary Tuberculosis

Pulmonary tuberculosis is transmitted via aerosolized droplets containing the acid-fast bacterium, mycobacterium tuberculosis. Because this bacterium is surrounded by a waxy capsule, it is more resistant to destruction than many other microorganisms. The body's response to the bacterium also differs from the usual acute inflammatory reaction. The mycobacteria are walled off by groups of monocytes and lymphocytes. The central portion of this cellular aggregation usually becomes necrotic. This nodular mass with central necrosis is called a granuloma, and the inflammatory process is known as granulomatous inflammation.

In healthy individuals with strong immune systems, this inflammation heals by scarring. In immunocompromised people, or in people who have inhaled a large number of organisms, inflammation progresses and causes more extensive destruction of lung tissue. If the granulomatous inflammatory process makes contact with a bronchus, necrotic inflammatory tissue is discharged into it. A cavity then forms within the lung, surrounded by granulomatous inflammatory tissue containing masses of the bacterium.
  

Respiratory Distress Syndrome of Newborns

This condition is characterized by progressive respiratory distress that occurs soon after birth and leads to serious problems with oxygenation. Premature infants, Cesarean section babies, and infants born to diabetic mothers are most often affected. The basic cause is inadequate surfectant in the infant's lungs. As a result, the alveoli do not expand properly during inspiration and often collapse with expiration. The permeability of the capillaries is also increased, allowing fibrinogen-rich fluid to leak into the alveoli. This fluid clots and adheres to the bronchial airways, further impeding respiration.
  

Bronchopulmonary Dysplasia

Bronchopulmonary dysplasia (BPD) is a chronic lung disease that occurs most commonly in babies who have had respiratory problems in the first few days after birth. BPD is seen primarily in infants born prematurely who have required oxygen and mechanical ventilation or continuous positive airway pressure to manage their respiratory distress. BPD is diagnosed in infants older than four weeks who have persistent lung disease requiring continual supplemental oxygen and who have had abnormal chest x-rays. BPD infants often need hospitalization for respiratory infections since their breathing status and supplemental oxygen requirements change rapidly even with minor infections. BPD infants often require supplemental oxygen continuously to avoid complications of inadequate oxygen, such as heart failure or poor growth and development.
 

Acute Respiratory Failure

Respiratory failure is respiratory dysfunction resulting in decreased oxygenation (hypoxemia) or carbon dioxide retention (hypercapnia) severe enough to threaten the function of vital organs. Acute respiratory failure occurs in both pulmonary and nonpulmonary diseases. Signs and symptoms of acute respiratory failure include dyspnea, headache, cyanosis, delirium, anxiety, hypertension, tachycardia, cardiac arrhythmias, and tremor. Arterial blood gas criteria for acute respiratory failure are not absolute, but in general values will indicate hypercapnia (pCO₂ over 50) and hypoxemia (pO₂ of less than 60).
  

Interstitial Lung Disease/Pulmonary Fibrosis

The tissue between the alveoli is referred to as the interstitium. Interstitial Lung Disease (ILD) and pulmonary fibrosis are general terms that include over 30 chronic lung disorders affecting the interstitium. Both terms refer to the same range of diseases. The conditions usually result from chronic exposure to lung irritants such as asbestos, coal dust, grain dust, or other atmospheric pollutants. If no cause can be found for the presence of the disease, it is referred to as idiopathic pulmonary fibrosis. All forms of ILD begin with an inflammatory process. The inflammation may affect different parts of the lung: the walls of the bronchioles (bronchiolitis), the walls of the alveoli (alveolitis), or the capillaries of the lungs (vasculitis). Over time, the inflamed tissues thicken and become fibrotic, making the lungs increasingly rigid and restricting normal respiratory expansion and contraction. The diffusion of oxygen and carbon dioxide between the alveoli and their capillaries is impaired due to the thickened tissue. The level of disability that a person experiences depends on the amount of scarring.
  

Malignant Mesothelioma

Malignant mesotheliomas are primary tumors arising from the surface lining of the pleura. Men with the disease outnumber women by a 3:1 ratio. Numerous studies have confirmed the association of malignant mesothelioma with asbestos exposure. The disease spreads quickly along the pleural surface and sometimes extends beyond the thoracic cavity.
  

Cystic Fibrosis

Cystic fibrosis (CF) is the most common fatal genetic disease in the United States today, affecting approximately 30,000 children and young adults. One in 29 Americans is an unknowing carrier of the defective gene.

The basic defect in CF cells is the faulty transport of sodium and chloride (salt) within epithelial lining of organs such as the lungs and pancreas to their outer surfaces. CF causes the body to produce an abnormally thick, sticky mucus. This abnormal mucus clogs the lungs and leads to fatal infections. The thick CF mucus also obstructs the pancreas, preventing enzymes from reaching the intestines to digest food.
  

Bronchogenic Carcinomas

Lung cancer accounts for 34% of cancer deaths in men and 21% of cancer deaths in women. Cigarette smoking is the most important cause of lung cancer in both men and women in the US. Other contributing factors include industrial pollutants, radiation, including radon gas and therapeutic radiation, asbestos, and heavy metals.

Ninety percent of malignant lung cancers belong to one of 4 major cell types. Squamous cell carcinoma and adenocarcinoma account for 65% of all malignant bronchogenic neoplasms; small cell carcinoma is responsible for about 20%, and large cell carcinoma 15%. Other malignant tumors of the lung include adenosquamous carcinoma, carcinoid tumor, bronchial gland carcinomas, and other rare tumors.

The clinical features of lung cancer depend upon the cell type and location of the primary tumor, its metastases and systemic effects. Only 10-25% of patients are asymptomatic when initial diagnosis is made. Symptomatic lung cancer is usually advanced and not resectable.

Diagnostic Tests

Pulmonary Function Tests

Pulmonary function tests (PFTs) are used to evaluate the efficiency of ventilation and gas exchange. These tests are helpful in determining the extent of obstructive and restrictive lung diseases. Pulmonary ventilation is usually tested by measuring the volume of air that can be moved in and out of the lung under standard conditions. Two commonly used measurements are forced vital capacity (FVC), which measures the maximum volume of air that can be expelled after a deep inspiration; and the one-second forced expiratory volume (FEV₁), which measures the maximum volume of air that can be expelled in one second. Specialized tests can be done to measure the total volume of air in the lungs and the volume of air remaining in the lungs after maximum expiration.
  

Arterial Blood Gases (ABGs)

Arterial blood gase analysis measures the concentrations of oxygen and carbon dioxide (pO₂ and pCO₂) in arterial blood in order to determine the efficiency of gas exchange in the lungs. It is usually performed on a small amount of blood obtained from the radial artery in the wrist. In chronic lung disease, oxygenation of the blood is inefficient, and arterial oxygen saturation is decreased correspondingly. Often the arterial carbon dioxide is higher than normal because the lungs inefficiently eliminate carbon dioxide.
  

Pulmonary Exercise Stress Testing

Pulmonary stress testing is usually performed on patients with unexplained exertional dyspnea. A bicycle ergometer or treadmill is used and heart rate, blood pressure, respiratory rate, oxygen saturation, and carbon dioxide ventilation are monitored during the test.
  

Diagnostic Bronchoscopy

Bronchoscopy is an examination of the trachea, bronchi, and bronchopulmonary segments. The procedure may be performed with a rigid or flexible bronchoscope, and the entry route may be either transoral or transnasal. The bronchoscope uses fiber light bundles to visualize the airway and, if needed, to obtain cytology and tissue samples for pathologic study.  

Surgical Procedures

Tracheostomy

This procedure is often performed when preparing a patient for mechanical ventilatory support. A small horizontal neck incision is made down through muscle to expose the trachea, the trachea is then incised and an airway is inserted. A stoma is created by suturing the skin to the tissue layers.
  

Surgical Bronchoscopy

Various surgical procedures may be performed through a bronchoscope. When coding bronchoscopies, read the operative report thoroughly to correctly identify all procedures performed.

• For bronchial biopsies, fluoroscopy is often used to assist with navigation of the scope's tip to the site of abnormal tissue. Closed biopsy forceps are then passed through a channel in the scope to obtain a tissue sample.
    
• Endoscopic dilation of a stenotic portion of the trachea or bronchus may be performed via placement of a guidewire through the bronchoscope. The scope is then removed, and the site is dilated with a series of dilators or stents to open the airway.
    
• Pulmonary abscess aspiration may be done with passage of a needle via the scope into abscess fluid and drainage through the needle.
    
• A transbronchial biopsy is a type of bronchoscopic biopsy that involves punching a hole through the wall of the bronchus into the lung to obtain a lung tissue sample. Be sure to check the pathology report whenever a bronchoscopy with biopsy is performed to determine what type of tissue was submitted.
     

Thoracoscopy

Like bronchoscopy, this procedure may be diagnostic or surgical in nature. A small incision is made between two ribs, a trocar is passed into the thoracic cavity, and the endoscope is passed through the trocar. The lung is usually partially collapsed by instilling air into the chest through the trocar. The thoracic cavity is then visualized. As with bronchoscopy, various surgical procedures may be performed at the time of thoracoscopy, including biopsy of the lungs or pleural tissues and removal of foreign bodies.
  

Pleurodesis

Pleurodesis is performed for persistent pneumothorax and for treatment of pleural effusions. In chemical pleurodesis the surgeon punctures the pleural cavity with a trocar. A catheter is advanced through the trocar into the chest. The trocar is removed and the surgeon injects a chemical such as tetracycline hydrochloride into the chest cavity via a syringe attached to the outside end of the catheter. The chemical induces adhesion between the parietal and visceral pleura. In mechanical pleurodesis the surfaces of the visceral and parietal pleura are abraded or roughened to form the adhesions.
  

Thoracentesis

This procedure removes fluid from the thoracic cavity. The thorax is entered percutaneously via a trocar, a catheter is introduced, and fluid is drained out of the thorax through the catheter. It is important to note that the lung is not punctured during thoracentesis. The outside end of the catheter is sometimes attached to a water seal system to prevent air from entering the thoracic cavity.
  

Pneumonocentesis

Pneumonocentesis is similar to thoracentesis. However, in this procedure the trocar is passed through the visceral pleura into the lung for drainage of a lung abscess or other fluid collection.
  

Pleurectomy

A pleurectomy is performed to remove thickened pleural membrane that prevents adequate lung expansion. The procedure is done via an open thoracotomy or sternotomy incision. Once the thoracic cavity is entered, the surgeon strips the constricting pleural membrane off the lung surface, and then proceeds to strip the parietal pleura from the inside surface of the chest cavity.
  

Excision-Plication/Lung Volume Reduction

This is an open procedure to remove part of an emphysematous lung. Access to the thoracic cavity is either via a sternal split or transthoracic incision. The surgeon isolates the lung tissue to be removed with sponges or staples. The diseased tissue is excised, and the wound is closed with sutures or wire as appropriate. A chest tube may be inserted to provide drainage from the thoracic cavity.

Total Pneumonectomy, Bilobectomy, Lobectomy, Segmentectomy

These terms refer to the excision of an entire lung, two lobes, a single lobe, or part of a lobe, respectively. All of them are open procedures done either via a vertical sternotomy incision or horizontal transthoracic incision. A chest tube is usually placed at closure to provide postoperative drainage.
  

Mechanical Ventilation

Many patients with respiratory distress syndrome or acute respiratory failure require assisted mechanical ventilation. A mechanical ventilator is applied with a mask covering the nose and mouth, via oral endotracheal intubation, or via surgical tracheostomy with intubation. Various adjustments to ventilatory volumes and pressures enable breathing until the patient can be weaned off the device and breathe independently.

Coding Tips and Guidelines

• When coding a respiratory infection, assign a secondary code to identify the infectious organism if known. And if it's not easily discernible, check the lab values and culture reports.
    
• When the physician documents pneumonia, attempt to further specify the type of pneumonia as well as the organism. If possible, avoid overuse of code 486 (pneumonia, organism unspecified). Remember that negative culture results do not always preclude the possibility of a bacterial infection. When in doubt, ask the attending physician.
    
• Choose the code for aspiration pneumonia based upon the type of ingestion that occurred: food or vomitus (507.0), oil or essences (507.1), solids (non-food), or liquids (507.8). Remember to assign two codes if both aspiration and bacterial pneumonia are present.
    
• A single ICD-9-CM code (496) exists for COPD. If COPD is documented with an additional component condition of emphysema, chronic bronchitis, alveolitis, asthma, or bronchiectasis, code the component condition.
    
• Do not assign a code for respiratory insufficiency in the presence of COPD since it is ordinarily considered part of the disease process.
    
• An acute exacerbation of chronic bronchitis requires only one code, 491.21.
    
• When coding a pneumothorax, note the type of pneumothorax. A spontaneous pneumothorax is coded as the principal diagnosis with the underlying condition coded as a secondary. A pneumothorax due to medical intervention is coded to 997.3, Complications affecting body systems, NEC, respiratory complications. A traumatic pneumothorax requires the use of two codes: one to describe the pneumothorax, and one to identify the wound of the specified body part.
    
• Bronchiolitis obliterans with organizing pneumonia (BOOP) is coded to 516.8. If the organism is known, remember to apply a secondary code.
    
• The sequencing of respiratory failure depends upon the circumstances of the admission:

1. Respiratory failure due to or associated with a chronic, non-respiratory condition: respiratory failure is the principal diagnosis.
     
2. Respiratory failure due to an acute exacerbation of a chronic, non-respiratory condition: the non-respiratory condition is the principal diagnosis.
     
3. Respiratory failure due to or associated with an acute non-respiratory condition: the acute condition is the principal diagnosis.

• Verify the type of tissue (lung or bronchus) biopsied when coding bronchoscopy.
    
• Bronchoscopy with brushings and washings is considered a biopsy in ICD-9-CM (33.24); in CPT-4 it is considered a diagnostic procedure (31622, 31623). Be aware of the differences between these two coding systems.
    
• Per the American Medical Association, when a bronchoscopy with brushings or washings is performed with a biopsy, assign two CPT-4 codes to correctly identify all procedural components (31622 or 31623 AND 31625 or 31628).
    
• An emergency endotracheal intubation (31500) is not a gastric tube insertion. The insertion of an endotracheal tube and nasogastric tube is similar, but the endotracheal tube goes to the trachea and the nasogastric tube goes to the stomach. It can be easy to assign the wrong code unless all documentation was carefully reviewed.
    
• Tracheostomies can be big DRG-boosters. Carefully review critical care cases, particularly those where mechanical ventilation was required, so that a tracheostomy is not overlooked. The probability of tracheostomy increases the longer a patient is on a ventilator.

Practice Makes Perfect!

Are you ready for some hands-on practice?

Read the patient report(s) on our procedure practice page. Assign the appropriate codes and then compare your answers with our coding recommendations. Good luck!

Back to:
Top - Anatomy - Respiratory Diseases and Disorders
Diagnostic Tests - Surgical Procedures - Coding Tips and Guidelines
   

If you have comments or suggestions about our code selections or about any topic on our Coding Edge® pages, please e-mail us at codingedge@lagunamedsys.com.