Vaping illnesses or lung diseases associated with e-cigarette use in the United States are evoking much concern among healthcare providers and public health officials. As of October 22, 2019, 1,604 cases of e-cigarette, or vaping, product use associated lung injury (EVALI) have been reported to the CDC from 49 states (all except Alaska), the District of Columbia, and 1 U.S. territory. The CDC also confirms thirty-four deaths from in 24 states (as of October 22, 2019). On Oct. 17, the Centers for Disease Control and Prevention (CDC) announced diagnosis coding guidance regarding EVALI. The guidance for EVALI, which is retroactive to Oct. 1, 2019 discharges, will be updated as necessary as new clinical information becomes available. Outsourcing companies providing coding and medical billing serviceswill keep track of the updates to help clinician report this lung injury correctly.

Guidance for Clinical Evaluation and Management of Patients with Suspected EVALI — Key Points

The reported symptoms of EVALI are:

  •  Respiratory – Cough, shortness of breath, or chest pain
  •  Gastrointestinal – Nausea, vomiting, or diarrhea
  •  Constitutional – fatigue, fever, or weight loss

Based on data available in late August, the CDC released the following interim guidance for health care providers evaluating patients with suspected e-cigarette or vaping, product use associated lung injury:

  • Patient history: Health care providers should ask patients about the use of e-cigarette, or vaping, products and ideally, also about types of substances used. Empathetic methods should be employed when evaluating patients for EVALI.
  • Physical exam: For patients who report the use of e-cigarette, or vaping, products, physical examination should include vital signs and pulse-oximetry.
  • Laboratory testing: Lab testing should be guided by clinical findings. During influenza season, a respiratory virus panel, including influenza testing is strongly recommeded. Additional testing should be based on published guidelines for evaluation of community-acquired pneumonia.
  • Imaging: Pulmonary infiltrates on a chest radiograph (CXR) and opacities on chest computed tomography (CT) scan are the imaging tests that can provide evidence of EVALI.
  • Consultation with specialists: Based on individual considerations, patients with suspected EVALI may need to be evaluated by several specialists to optimize management. In addition to pulmonologists, consultations may be necessary with medical toxicology, infectious disease, psychology, psychiatry, addiction medicine, and other specialists.
  • Management: Hospital admission is recommended for patients who have decreased blood oxygen saturation on room air or who are in respiratory distress. An empiric use of a combination of antibiotics, antivirals, or steroids is recommended based upon clinical context. Evidence-based tobacco product cessation strategies, including behavioural counseling, are recommended to help patients stop using e-cigarette, or vaping, products.

Coding Guidance for EVALI

On October 17, the CDC announced new coding guidance regarding e-cigarette lung injuries based on available clinical information. This latest guidance should be used in conjunction with the Official Coding Guidelines for ICD-10 2020.

  • Lung-related complications: Lung-related conditions associated with e-cigarette use should be assigned the code for the specific condition, such as:
    • J68.0 (Bronchitis and pneumonitis due to chemicals, gases, fumes and vapors)
    • J69.1 (Pneumonitis due to inhalation of oils and essences)
    • J80 (Acute respiratory distress syndrome)
    • J82 (Pulmonary eosinophilia, not elsewhere classified)
    • J84.114 (Acute interstitial pneumonitis)
    • J84.89 (Other specified interstitial pulmonary disease).

Acute lung injury: ICD-10 codes to use if the documentation indicates acute lung injury but does not identify a specific condition:

    • J68.9  (Unspecified respiratory condition due to chemicals, gases, fumes, and vapors) for  acute lung injury reported without specifics
    • T65.291 for poisoning/toxic effect is due to nicotine
    • T40.7X-for poisoning/toxic effect is due to THC

Report the seventh character A, D, or S based on the patient’s presentation

  • Poisoning and toxicity: For acute nicotine exposure (swallowing, breathing, or absorbing e-cigarette liquid through skin or eyes) in children and adults, use:
    • T65.291- Toxic effect of other nicotine and tobacco, accidental (unintentional); includes
      Toxic effect of other tobacco and nicotine NOS.
    • For acute tetrahydrocannabinol (THC) toxicity, use:

    • T40.7X1-Poisoning by cannabis (derivatives), accidental (unintentional)
  • Substance use, abuse, and dependence:

If substance use/abuse/dependence is documented, assign additional codes identifying the substance(s) used. To report use, abuse and dependence of the same substance (e.g. nicotine, cannabis, etc.), assign only one code identify the pattern of use based on the following hierarchy:

  • Report only code for abuse if both use and abuse are documented
  • Report only the code for dependence if both abuse and dependence are documented
  • Report only the code for dependence if use, abuse and dependence are all documented
  • Report only the code for dependence if both use and dependence are documented

As many codes as appropriate should be assigned, such as:

    • F12.- Cannabis related disorders
    • F17.- Nicotine related disorders
    •  
      For vaping of nicotine, assign:

    • F17.29- Nicotine dependence, other tobacco products. Electronic nicotine delivery systems (ENDS) are non-combustible tobacco products

    Coding signs and symptoms

    When a definitive diagnosis has not been established, but the patient presents with signs/symptoms (such as fever, etc.), code each of the presenting signs and symptoms.

    Examples:

      • M79.10 Myalgia, unspecified site
      • R06.00 Dyspnea, unspecified
      • R06.02 Shortness of breath
      • R06.2 Wheezing
      • R06.82 Tachypnea, not elsewhere classified
      • R07.9 Chest pain, unspecified
      • R09.02 Hypoxemia
      • R09.89 Other specified symptoms and signs involving the circulatory and respiratory systems (includes chest congestion)
      • R10.84 Generalized abdominal pain
      • R10.9 Unspecified abdominal pain
      • R11.10 Vomiting, unspecified
      • R11.11 Vomiting without nausea
      • R11.2 Nausea with vomiting, unspecified
      • R19.7 Diarrhea, unspecified
      • R50.- Fever of other and unknown origin
      • R53.83 Other fatigue
      • R61 Generalized hyperhidrosis (night sweats)
      • R63.4 Abnormal weight loss
      • R68.83 Chills (without fever)

    The CDC reports that proposals for a new code would be presented at the Coordination and Maintenance Committee meeting in March 2020. On October 22, NPR reported that the CDC has started studying lung tissue and chemicals from e-cigarette vapor to identify the root cause of lung damage caused by vaping.

    CDC’s Recommendations to the Public 

    • People should not use any type of e-cigarette, or vaping, products, particularly those containing tetrahydrocannabinol (THC), off the street or modify or add any substances to e-cigarette, or vaping, products not intended by the manufacturer.
    • E-cigarette, or vaping, products that contain nicotine should be avoided.
    • E-cigarette, or vaping, products should never be used by youths, young adults, or women who are pregnant.
    • Persons who do not currently use tobacco products should not start using e-cigarette, or vaping, products.
    • An adult using e-cigarettes, or vaping, products to quit smoking, should not return to smoking cigarettes. Adults addicted to nicotine using e-cigarettes should weigh all risks and benefits and consider utilizing FDA-approved nicotine replacement therapies.
    • Users of an e-cigarette or vaping, product should carefully monitor for symptoms and see a healthcare provider immediately if they develop symptoms like those reported in this outbreak.
    • Persons with marijuana use disorder should seek evidence-based treatment by a health care provider.

    Physicians reporting vaping cases can rely on coding professionals in medical billing outsourcing companies to code diagnosis and treatment correctly.