With temperatures turning cooler, individuals with pulmonary diseases such as Chronic Obstructive Pulmonary Disease (COPD) and asthma face risk of exacerbation of their condition. As COPD and asthma have common features, differentiating them can be complicated, according to the American Academy of Family Physicians (AAFP). Practices also need to ensure accurate and up-to-date coding and proper documentation to ensure quality care and appropriate reimbursement, and avoid risk of audit. As physicians focus on diagnosing these chronic diseases and helping patients maximize lung function and manage exacerbations, medical billing outsourcing is a practical option to ensure accurate claim submission and payment.
Asthma
Asthma is a chronic disease of the airways. The condition causes the bronchial tubes to become swollen or inflamed, restricting air supply to and from the lungs. Asthma is caused by a combination of environmental and hereditary factors. Asthma triggers differ from person to person and include: pollen, dust mites, mold, pet hair, respiratory infections, physical activity, cold air, smoke, certain medications, some preservatives in foods and beverages, stress, and gastroesophageal reflux disease (GERD). According to the Centers for Disease Control’s (CDC), 1 in 13 people in the U.S. have asthma. More than 25 million Americans have asthma and it is the leading chronic disease in children.
COPD
COPD is a major cause of disability and a leading cause of death in the United States. This chronic lung disease is characterized by obstructed airflow from the lungs. Smoking is the most common cause of COPD According to the Mayo Clinic, 20 to 30 percent of people who smoke on a regular basis develop COPD. The disease can also be the result of a genetic disorder. COPD can be made worse by exposure to environmental pollutants. Emphysema and chronic bronchitis are the two most common types of COPD. According to the AAFP, in 2010, COPD was the primary diagnosis in 10.3 million physician office visits, 1.5 million emergency department (ED) visits, and 699,000 hospital discharges. The American Lung Association (ALA) estimates that there may be as many as 24 million American adults living with COPD (Healthline, 2018).
Both asthma and COPD are treatable. With proper management, most people with COPD can achieve good symptom control and quality of life, as well as reduced risk of other associated conditions.
Distinguishing between Asthma and COPD
The AAFP lists the primary features of asthma and COPD as follows:
| Asthma | COPD |
| Onset before age 20 years | Onset after age 40 |
| Symptoms that vary over time, often limiting activity | Persistence of symptoms despite treatment |
| A record (e.g., spirometry, peak expiratory flow [PEF]) of variable airflow limitation | Abnormal lung function between symptoms |
| Family history of asthma or other allergic condition | Heavy exposure to risk factors, such as tobacco smoke or biomass fuels |
| Lung function that may be normal between symptoms | Symptoms that worsen slowly over time (i.e., progressive course over years) |
| Symptoms that vary either seasonally or from year to year | Limited relief from rapid-acting bronchodilator treatment |
| Symptoms that improve spontaneously or have an immediate response to bronchodilator treatment or to inhaled corticosteroids (ICS) over a period of weeks | Severe hyperinflation or other changes on chest X-ray |
| Normal chest X-ray |
Distinguishing between COPD and asthma can have significant implications for management and life expectancy. As these conditions have many common features, the AAFP recommends that an approach that focuses on the features that can correctly distinguish asthma from COPD. To diagnose asthma or COPD, physicians need to perform a careful history that considers age; symptoms (especially onset and progression, variability, seasonality or periodicity, and persistence); history; social and occupational risk factors (including smoking history, previous diagnoses, and treatment); and response to treatment.
ICD-10 Codes for Asthma and COPD
- Asthma: The Asthma ICD-10 Codes fall under Category J45.- This category includes: Allergic (predominantly) asthma; Allergic bronchitis NOS; Allergic rhinitis with asthma; Atopic asthma; Extrinsic allergic asthma; Hay fever with asthma; Idiosyncratic asthma; Intrinsic nonallergic asthma, and Nonallergic asthma.
- J45.20 Mild intermittent asthma, uncomplicated
- J45.21 Mild intermittent asthma with (acute) exacerbation
- J45.22 Mild intermittent asthma with status asthmaticus
- J45.30 Mild persistent asthma, uncomplicated
- J45.31 Mild persistent asthma with (acute) exacerbation
- J45.32 Mild persistent asthma with status asthmaticus
- J45.40 Moderate persistent asthma, uncomplicated
- J45.41 Moderate persistent asthma with (acute) exacerbation
- J45.42 Moderate persistent asthma with status asthmaticus
- J45.50 Severe persistent asthma, uncomplicated
- J45.51 Severe persistent asthma with (acute) exacerbation
- J45.52 Severe persistent asthma with status asthmaticus
- J45.901 Unspecified asthma with (acute) exacerbation
- J45.902 Unspecified asthma with status asthmaticus
- J45.909 Unspecified asthma, uncomplicated
- J45.990 Exercise-induced bronchospasm
- J45.991 Cough variant asthma
- J45.998 Other asthma
- COPD: ICD-10 classifies diseases that fall under COPD to category J44.This category includes the following: 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, and chronic obstructive tracheobronchitis. The ICD codes for COPD are:
- J44.0 (Chronic obstructive pulmonary disease with acute lower respiratory infection). Use an additional code to identify the infection.
- J44.1(Chronic obstructive pulmonary disease with [acute] exacerbation)
Decompensated COPD
Decompensated COPD with (acute) exacerbation - J44.9(Chronic obstructive pulmonary disease, unspecified)
Chronic obstructive airway disease
NOS Chronic obstructive lung disease NOS
Points to Note when Coding Asthma and COPD
- When coding asthma, an additional code should be used to identify: Exposure to environmental tobacco smoke (Z77.22); History of tobacco use (Z87.891); Occupational exposure to environmental tobacco smoke (Z57.31); Tobacco dependence (F17.-), and Tobacco use (Z72.0)
- If the documentation indicates both COPD and asthma, without any further specificity of the type of asthma, only COPD would be reported (www.hiacode.com). According to the instructional notes under Category J44, Other chronic obstructive pulmonary disease, the type of asthma should also be coded, if applicable (J45-). No additional code needs to be assigned for unspecified asthma. If the unspecified asthma is documented to be in exacerbation, it would be coded in addition to the COPD. Exacerbation of unspecified asthma provides additional specificity regarding the asthma being in acute exacerbation.
- Both asthma and COPD codes can be reported if the documentation indicates that the patient has a specific type of asthma as well as COPD. Codes should be assigned based upon the specificity of the COPD and asthma documented.
- Each condition (COPD and asthma) would need to be documented as exacerbated in order to code to this specificity. If one of these conditions is documented as exacerbated, this does not automatically imply that the other condition is also exacerbated.
- Excludes 1 and Excludes notes are integral to correct coding. Familiarity with the Excludes 1 and Excludes 2 notes for asthma and COPD codes are crucial to prevent claim denials. Updating databases to contain the Excludes 1 rules are key to ensuring that clean claims are being submitted to payers (www.aapc.com).
Physicians need to focus on accurate chart documentation and diagnosis reporting for these pulmonary conditions. With proper documentation, an experienced family practice medical billing company can help them assign the right codes and ensure optimal reimbursement.
Rajeev Rajagopal, the President of OSI, has a wealth of experience as a healthcare business consultant in the United States. He has a keen understanding of current medical billing and coding standards.