February 2, 2015

Clinical Documentation Improvement by Service – Pulmonology and Respiratory Surgery


Editor’s Note: This is the fourth article in the continuation of a series of articles on clinical documentation improvement by clinical service.

We have turned the calendar to a new year, and as such, we will look at a new service: pulmonology and respiratory surgery, both of which may present some challenges under ICD-10-CM/PCS. What are the required documentation updates? Let’s take a look at some examples.


Pneumonia: There are still entries for bacterial, aspiration, and viral pneumonia. There is no longer a subentry for “lobar.” This sub-term is included as a non-essential modifier for some of the subentries. Any known bacteria or virus would be an important essential modifier for pneumonia, which is the same as it was in ICD-9-CM. Drug resistance may be indicated along with the pneumonia or bacteria, or it can be identified using the category Z16. Something new in ICD-10-CM is the ability to identify a condition as nosocomial (Y95). The Coding Clinic for ICD-10-CM/PCS published in 2013 indicates that it is appropriate to add Y95 for a documented healthcare acquired condition. There is a trend in the documentation of “healthcare acquired pneumonia,” so the assigned codes would be the appropriate pneumonia code (e.g. J18.9) plus Y95. In the same issue of Coding Clinic, there is an entry noting that hemoptysis with pneumonia should be coded as R04.2 with the appropriate pneumonia code. Hemoptysis is not routinely present with pneumonia.

Respiratory Failure: The default for respiratory failure is no longer “acute.” This change represents a big impact for the documentation of respiratory failure. Documentation must include the term “acute,” “chronic,” or “acute on chronic.” ICD-10-CM adds sub-terms of hypercapnia and hypoxia so that the coder can provide more specificity regarding the patient’s condition. If the patient has hypercapnia and hypoxia, then both codes would be assigned. Please note that there is a code for post-procedural respiratory failure as well, and it can be found in the Respiratory chapter. Documentation would be required to associate the respiratory failure with the procedure. Guidance has not yet been published regarding the sequencing of respiratory failure with acute or chronic respiratory conditions. 

Lung Neoplasms: There are not many changes with regard to lung neoplasms. The same behavior groupings are present in ICD-10-CM. The coder will note that an additional subentry “mesothelioma” has been added under the site of “lung.” The term “contiguous sites” now indicates overlapping sites. The other change is the use of laterality. The Table of Neoplasms features a dash after the code to indicate that the tabular volume should be referenced to obtain the remainder of the code. The documentation of laterality is provided by the physician today, but the coder cannot use the documentation in the diagnosis code assignment.

Asthma: The biggest documentation change is associated with asthma. Asthma should be documented with a type – intermittent or persistent – and a severity of mild, moderate, or severe. An additional modifier can be included regarding presentation – acute exacerbation or status asthmaticus. This terminology updates the classification used by the American Lung Association. There is a tool available on the association’s website, www.lung.org, that provides information regarding the characteristics and treatment of each type along with severity.  

Bronchoscopy: The important documentation for this procedure includes the approach (through natural/artificial orifice, using an incision, or inserting the scope through the skin), any biopsies that might have been obtained, and the anatomic location of the biopsy sites. Other important documentation is the goal of the procedure – is it therapeutic or investigative? The ICD-9-CM procedure was coded beginning with the term “bronchoscopy,” but ICD-10-PCS will begin with the root operation, which explains the goal of the procedure.  

Insertion of Chest Tubes: Chest tubes are used as drainage devices. In ICD-10-PCS, the root operation would be drainage. Laterality is also included in the body part – left or right pleural cavity. In ICD-9-CM, the code was identified beginning with “Insertion,” which is the surgeon’s responsibility. The approaches are the same with both classification systems – open, endoscopic, and percutaneous.  

Thoracentesis: A thoracentesis can be performed to obtain a specimen or for therapeutic drainage when a patient has pleural effusion. ICD-10-PCS includes a qualifier (seventh character) of diagnostic or no qualifier. Therapeutic thoracentesis would have a qualifier of “no qualifier,” which indicates that it is a therapeutic procedure (i.e. it is not diagnostic). A diagnostic thoracentesis may be performed when a patient has pleural effusion that is suspected to be malignant. 

This exploration of pulmonology and respiratory surgery indicates that there are some changes regarding these conditions and procedures, but there are more significant changes to the procedures. It is important to acknowledge that the documentation of asthma is significant. The next article in the series will focus on gynecology and obstetrics.

Disclaimer: Every reasonable effort was made to ensure the accuracy of this information at the time it was published. However, due to the nature of industry changes over time we cannot guarantee its validity after the year it was published.
Laurie Johnson, MS, RHIA, CPC-H, FAHIMA, AHIMA-Approved ICD-10-CM/PCS Trainer

Laurie M. Johnson, MS, RHIA, FAHIMA is currently a senior healthcare consultant for Revenue Cycle Solutions, based in Pittsburgh, Pa. Laurie is an American Health Information Management Association (AHIMA) approved ICD-10-CM/PCS trainer. She has more than 35 years of experience in health information management and specializes in coding and related functions. She has been a featured speaker in over 40 conferences. Laurie is a member of the ICD10monitor editorial board and makes frequent appearances on Talk Ten Tuesdays.