Coding Consult

October 8, 2004

Controlled Asthma

You can avoid claim rejections for improper asthma coding if you know how to use 493.xx's revised fifth digit. Here's what the digits stand for now:

So, if your patient is stable, use "0" as the fifth digit. If your patient has exacerbation or status, "0" would be inappropriate.

"If a patient has an exacerbation that's been going on for a couple of weeks," explains Jeffrey Linzer Sr., a physician and ICD-9-CM Editorial Advisory Board representative, "I might write on the record 'subacute exacerbation,' but still go to 'with (acute) exacerbation' for the code. Before this revision, you might take 'acute' literally and think you'd have to use the '0' fifth digit (unspecified) for a subacute condition. Now you'd use '2'." Let's say an extrinsic asthma patient presents with wheezing. In this case, you should report 493.02 (asthma; extrinsic asthma; with [acute] exacerbation), says Maria M. Torres, of Bermudez Medical Consulting Services in Tampa. The "2" signifies that something exacerbated the patient's asthma.

Jean S. Oglevee, coding compliance coordinator at Family Medicine Clifton/Centreville in Centreville, VA, says that for routine extrinsic asthma visits, she previously reported 493.00. The fifth-digit "0" indicated the patient had "extrinsic asthma, without mention of status or an acute exacerbation or unspecified." But 493.00 now translates to "extrinsic asthma, unspecified."

"Unspecified" may not trigger a denial "The revisions are editorial clarifications," says Linzer. "They're not a big deal. The codes basically still mean the same. A patient is either in status asthmaticus, or has an exacerbation, or he doesn't have either."

For instance, a 45-year-old-male extrinsic asthma patient presents with a little chest tightness. He isn't in distress but needs to renew his nebulizer prescription. For the routine, controlled extrinsic asthma visit, you should use 493.00, as you previously did. The code still describes a stable, extrinsic asthmatic.

The snag is that "as a rule, we don't use nonspecific codes," Oglevee says. The designation usually triggers a denial, and that would cut about $52 from your revenue from 99213 (office or other outpatient visit for the evaluation and management of an established patient . . .) in the above controlled asthmatic scenario. (The fee is based on the 2004 Medicare Physician Fee Schedule, available at http://www.cms.hhs.gov/physicians/pfs )

But sometimes you should use unspecified codes, and in asthma cases, they may not trigger a denial.

If this is a new patient and you aren't familiar with his symptoms and history, report 493.x0. The "0" indicates that you're not specifying that the patient has status asthmaticus or an exacerbation. But never use an unspecified code if you have information that the patient is status asthmaticus (fifth digit of 1) or that the patient is having an (acute) exacerbation (fifth digit of 2).

"The patient's chief complaint will often tell you which fifth digit to use," Torres says. If the patient had wheezing-even if it occurred the night before the patient presented-use 493.x2, she says.

If you're denied, appeal the decision "Why are we being put in the position that we have to use unspecified codes?" says Oglevee. "If the insurer sets up its system to deny all unspecified codes, these claims are going to be denied." In her opinion, especially with a condition as common as asthma, there should be a code for stable asthmatics.

"Instead we're told to use a code that likely will be denied. We try to supply as much specificity as possible so our claims go out clean, and with this, no code exists that's specific enough. We're trying to do this right, but we're put in a position where we can't. It's frustrating," says Oglevee. "I hope they'll change this situation next year."

Torres doesn't agree: "Insurers are paying on the unspecified code." She says even when she files an asthma claim with 493.x0 as the primary and only code, insurers still reimburse the E&M service.

If a payer denies the office visit, you should appeal the decision. In your cover letter, explain that the patient's asthma wasn't exacerbated or status asthmaticus. Therefore, you appropriately reported 493.x0 to indicate that the patient's asthma was controlled or you weren't familiar enough with the patient's history to make a 493.x1 or 493.x2 diagnosis.

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