Documenting and Coding Bronchitis – A Common Lung Infection

by | Dec 26, 2019 | Resources | 0 comments

Bronchitis occurs due to an inflammation of the lining of your bronchial tubes, which carry air to and from your lungs. In most cases, the condition occurs when an infection irritates and inflames the airways, causing them to produce more mucus than usual. The condition causes cough (that often brings up thickened mucus) and shortness of breath, wheezing, a low fever, and chest tightness. Bronchitis may be either acute or chronic. Acute bronchitis usually clears up, but chronic bronchitis is persistent and never completely goes away. Quitting or avoiding the habit of smoking can help prevent the condition in the long run. Pulmonologists or other specialists while diagnosing the symptoms should correctly document the procedures performed in the patients’ medical records. Correct diagnosis of bronchitis symptoms is very important to provide appropriate care and treatment at the right time. Outsourcing billing and coding tasks to a reliable medical billing and coding company can help physicians simplify their documentation process.

Bronchitis can occur when a virus, bacteria or irritant particles trigger an inflammation of the bronchial tubes. Smoking is a common risk factor for this condition, but non-smokers can also develop this condition. In addition, air pollution and dust or toxic gases in the environment or workplace also contribute to the condition.

Types of Bronchitis

Bronchitis can be either acute or chronic. Acute bronchitis, (also called chest cold) can result from a virus (for example, a cold or flu virus), bacterial infection and exposure to substances that irritate the lungs (such as tobacco smoke, dust, fumes, vapors, and air pollution). It usually improves within 7-10 days without lasting effects, although the cough may linger for weeks. Chronic bronchitis, on the other hand, results from repeated irritation and damage to the lung and airway tissues. Possible causes include – smoking, long term exposure to air pollution, dust, and fumes from the environment and other genetic factors.

Symptoms

Cough is one of the most common symptoms associated with the condition. The cough may be dry or it may produce phlegm – which suggests that the lower respiratory tract and the lungs may be infected. Continued, forceful coughing may be painful, and can make your chest and abdominal muscles sore and injure the chest wall, break ribs, or even cause a person to faint. Other related symptoms include –

  • Wheezing
  • Slight fever and chills
  • Shortness of breath
  • Production of mucus (sputum)
  • Headaches
  • Fatigue
  • Body aches
  • A sore throat
  • A feeling of tightness in the chest
  • A blocked nose and sinuses

While, these symptoms may usually improve within a week, patients may have a nagging cough that lingers for several weeks.

Diagnosis and Treatment

The signs and symptoms of the condition can be quite difficult to distinguish during the first few days of illness. In most cases, the symptoms may be similar to those of the common cold. Diagnosis will start with a physical examination; wherein your physician will use astethoscope to listen closely to your lungs. Physicians may also conduct a detailed review of medical history, recent bouts of cold or flu, smoking history and exposure to secondhand smoke, dust, fumes, or air pollution. They may take a sputum swab to test for bacteria or viruses in the laboratory. Tests like chest X-ray, pulmonary lung function test, or blood tests (to check the oxygen levels in the person’s blood) will also be recommended by the physician.

In most cases, acute bronchitis gets better without treatment, usually within a couple of weeks. Antibiotics and other medications will be recommended for people who suffer from bacterial infections. On the other hand, for people who have allergies, asthma or chronic obstructive pulmonary disease (COPD), physicians may recommend an inhaler and other medications to reduce inflammation and open the narrowed passages in the lungs. Pulmonary rehabilitation (a breathing exercise program) will be recommended for people with chronic bronchitis.

Documentation Requirements for Bronchitis

ICD-10 codes being more specific, your documentation should clearly specify the diagnosis, related symptoms and other conditions that will help choose the most appropriate codes. ICD-10 documentation for bronchitis must include the following criteria –

  • Type – The exact type of bronchitis should be considered and includes simple, mucopurulent, fibrinous, membranous, purulent, or septic bronchitis.
  • Temporal factors – Also called parameters, temporal factors include acute, chronic, acute or chronic, and recurrent.
  • Infectious agents – These agents include Streptococcus, Coxsackie virus, parainfluenza virus, respiratory syncytial virus, rhinovirus, Echovirus, Mycoplasma pneumoniae, Hemophilus influenza and other specified organisms.
  • Associated conditions – These conditions include tracheobronchitis, tracheitis and bronchospasm.
  • Causes – Possible causes include tobacco use/ dependence, tobacco smoke exposure (occupational or environmental) or history of tobacco use. It is essential to assign an additional ICD-10 code to specify this along with the diagnosis code for bronchitis.

ICD-10 Coding

The diagnostic tests and treatment procedures for bronchitis must be correctly documented using the right codes. An experienced medical billing company can help physicians report the correct billing codes. ICD-10 codes for bronchitis come under the category of J20 – which includes acute bronchitis and J40 – which includes chronic bronchitis.

Acute Bronchitis

  • J20 – Acute bronchitis
  • J20.0 – Acute bronchitis due to Mycoplasma pneumoniae
  • J20.1 – Acute bronchitis due to Hemophilus influenzae
  • J20.2 – Acute bronchitis due to streptococcus
  • J20.3 – Acute bronchitis due to coxsackievirus
  • J20.4 – Acute bronchitis due to parainfluenza virus
  • J20.5 – Acute bronchitis due to respiratory syncytial virus
  • J20.6 – Acute bronchitis due to rhinovirus
  • J20.7 – Acute bronchitis due to echovirus
  • J20.8 – Acute bronchitis due to other specified organisms
  • J20.9 – Acute bronchitis, unspecified

Chronic Bronchitis

  • J41 – Simple and mucopurulent chronic bronchitis
  • J41.0 – Simple chronic bronchitis
  • J41.1 – Mucopurulent chronic bronchitis
  • J41.8 – Mixed simple and mucopurulent chronic bronchitis
  • J42 – Unspecified chronic bronchitis

Though each subcategory comprises an unspecified code, it is essential to assign the following code if the documentation does not specify a time parameter.

  • J40 – Bronchitis, not specified as acute or chronic

Acute bronchitis is a common condition that can be either acute or chronic, but usually resolve within a few days. Chronic bronchitis is an ongoing condition that may develop worsening symptoms, emphysema, and COPD – if a person smokes and continues to smoke. Adopting several self-care measures like avoiding lung irritants (such as smoke, dust, fumes, vapors, and air pollution), using a humidifier, quitting the habit of smoking, wearing a mask (to cover the nose and mouth when pollution levels are high) and washing the hands often to limit exposure to germs and bacteria can reduce the risk of this condition in the long run.

Medical billing and coding for bronchitis can be complex, as there are different codes associated with the condition. By outsourcing these tasks to a reliable medical billing service provider that offers the services of AAPC-certified coding specialists, healthcare practices can ensure correct and timely medical billing and claims submission.