Category: Medi-Cal Managed Care


ICD-10-CM coding

Respiratory diseases are classified in categories J00 through J99 in Chapter 10, “Diseases of the Respiratory System” of the ICD-10-CM Official Guidelines for Coding and Reporting.

 

Pneumonia

Pneumonia is coded in several ways in ICD-10-CM. Combination codes that account for both pneumonia and the responsible organism are included in Chapter 1, “Certain Infectious And Parasitic Diseases” and Chapter 10, “Diseases of the Respiratory System.” Examples of appropriate codes for pneumonia include:

  • J15.0 — pneumonia due to Klebsiella
  • J15.211 — pneumonia due to Staphylococcus aureus
  • J11.08 + J12.9 — viral pneumonia with influenza.

 

Other types of pneumonia are coded as manifestations of underlying infections classified in chapter 1; two codes are required in such cases. Examples of this dual classification coding include I00 + J17 — pneumonia in rheumatic fever. When the diagnostic statement is pneumonia without any further specification and the organism is not identified, the assigned code is J18.9 — pneumonia, unspecified organism.

 

Influenza

ICD-10-CM classifies influenza as the following categories:

  • J09 — due to certain identified influenza viruses
  • J10 — due to other identified influenza virus
  • J11 — due to unidentified influenza virus.

 

Codes from categories J09 and J10 should be assigned only for confirmed cases of avian flu and other novel influenza A, or for other identified influenza virus.

 

Chronic obstructive pulmonary disease (COPD) and asthma

COPD is a general term used to describe a variety of conditions that result in obstruction of the airway. ICD-10-CM classifies these conditions to category J44, other chronic obstructive pulmonary disease. Category J44 includes the following conditions:

  • 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 bronchitis
  • Chronic obstructive tracheobronchitis

 

Category J44 is further subdivided to specify whether there is an acute lower respiratory infection (J44.0) and whether there is an exacerbation of the condition (J44.1). If applicable, a code from category J45 is assigned to specify the type of asthma. It is appropriate to code both the COPD with acute exacerbation and COPD with a lower respiratory infection. Be specific in the documentation, including the type of infection and the infective agent.

 

For COPD, document severity as either mild, moderate or severe. COPD can occur with or without acute or chronic respiratory failure, so any respiratory failure should be separately noted.

Asthma is classified into category J45; a fourth character indicates the severity as either mild intermittent, mild persistent, moderate persistent, severe persistent, other and unspecified; also, a final character indicates whether the condition is uncomplicated, or whether status asthmaticus or exacerbation is present.

 

Asthma characterized as obstructive or diagnosed in conjunction with COPD is classified to category J44 — other chronic obstructive pulmonary disease. If the specific type of asthma is documented, also use code J45.

 

Signs and symptoms of COPD or asthma that are separately reported when they occur include hypercapnia, hypoxemia, polycythemia, and acute or chronic respiratory failure. Document any dependence on a ventilator or supplemental oxygen.

 

A diagnosis of asthmatic bronchitis without further specification is coded as J45.9 if the diagnosis is stated as exacerbated or acute chronic asthmatic bronchitis, code J44.1 is assigned. A diagnosis of asthmatic bronchitis with COPD or chronic asthmatic bronchitis is coded to J44.9.

Examples of coding for asthma include the following:

  • J45.902 — asthmatic bronchitis with status asthmaticus
  • J44.9 + J45.40 — moderate persistent asthma with COPD.

 

In addition to codes in categories J44 and J45, codes may also be assigned to identify exposure to environmental tobacco smoke (Z77.22), history of tobacco dependence (Z87.891), occupational exposure to environmental tobacco smoke (Z57.31), tobacco dependence (F17. or tobacco use (Z72.0)

 

HEDIS® quality measures for respiratory conditions

 

Medication Management for People with Asthma (MMA)

This HEDIS measure looks at patients who have been identified as having persistent asthma and have been dispensed appropriate medication on which they remained during the treatment period.

 

HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).

 

Two rates are reported:

  • The percentage of patients who remained on an asthma controller medication for at least 50% of their treatment period
  • The percentage of patients who remained on an asthma controller medication for at least 75% of their treatment period

 

For patients with asthma, you should:

  • Prescribe controller medication.
  • Educate them on identifying asthma triggers and taking controller medications.
  • Create an asthma action plan (document in the medical record).
  • Remind them to get their controller medication filled regularly.
  • Remind them to continue taking the controller medications even if they are feeling better and free of symptoms.

 

Exclusions:

  • Acute respiratory failure
  • Chronic respiratory conditions due to fumes/vapors
  • COPD
  • Cystic fibrosis
  • Emphysema
  • Other emphysema

 

Asthma Medication Ratio (AMR)

This HEDIS measure looks at patients who were identified as having persistent asthma and had a ratio of controller medications to total asthma medications of 0.5 or greater during the measurement year.

 

Helpful tips:

  • For each member, count the units of asthma controller medications dispensed during the measurement year.
  • For each member, count the units of asthma reliever medications dispensed during the measurement year.
  • For each member, sum the units calculated in step 1 and step 2 to determine units of total asthma medications.
  • For each member, calculate the ratio of controller medications to total asthma medications (units of controller medications divided by units of total asthma).

 

Use of Spirometry Testing in the Assessment and Diagnosis of COPD (SPR)

This HEDIS measure looks at members 40 years of age and older with a new diagnosis of COPD or newly active COPD who received appropriate spirometry testing to confirm the diagnosis.

 

Helpful tips:

  • Managing chronic conditions takes planning. A pre-visit chart review is a good place to start.
  • Proper diagnosis is needed to ensure members receive appropriate short- and long-term treatment.
  • Both symptomatic and asymptomatic patients suspected of COPD should have spirometry performed to establish airway limitation and severity.

 

Resources:

  • ICD-10-CM Expert for Physicians: the complete official code set. Optum360, LLC. 2019.
  • ICD-10-CM/PCS Coding: theory and practice. 2019/2020 Edition. Elsevier
  • NCQA: HEDIS & performance management: https://www.ncqa.org/hedis/measures



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January 2020 Anthem Blue Cross Provider News - California