E-Cigs

CPR’s “Coding Corner” focuses on coding, compliance, and documentation issues relating specifically to physician billing. This month’s tip comes from Deborah Marsh, senior development editor for AAPC, a training and credentialing association for the business side of health care.

Thousands of cases of e-cigarette, or vaping, product use associated lung injury (EVALI) have been reported from across the U.S. to the Centers for Disease Control and Prevention. Physicians and medical coders can now turn to an official document for guidance on coding encounters related to e-cigarette use, covering EVALI, toxicity, dependence and symptoms. You also can look forward to potential new ICD-10 codes related to vaping.

The vaping coding guidance, posted Oct. 17, 2019, is authoritative because it is a supplement to the ICD-10-CM Official Coding Guidelines. The supplement was approved by the four Cooperating Parties for ICD-10: the National Center for Health Statistics, the American Health Information Management Association, the American Hospital Association, and the Centers for Medicare and Medicaid Services.

The supplement offers examples of codes that may be appropriate for EVALI cases, but keep in mind the document’s warning that you also may need to assign other codes for these encounters to comply with ICD-10 coding rules. In other words, follow any applicable rules in the ICD-10 Official Guidelines. Also be sure to check for notes in the ICD-10 Tabular List that apply to your chosen code, such as Excludes1 notes, code first notes and similar instructions.

Coding for EVALI encounters

The appropriate code for the EVALI diagnosis will depend on whether the documentation identifies a specific condition.

If you’re reporting a documented case of EVALI and the condition is specified, then you should select the code that represents that specified condition. The supplement provides the examples below.

  • J68.0 Bronchitis and pneumonitis due to chemicals, gases, fumes and vapors
    • Includes chemical pneumonitis
  • J69.1 Pneumonitis due to inhalation of oils and essences
    • Includes lipoid pneumonia
  • J80 Acute respiratory distress syndrome
  • J82 Pulmonary eosinophilia, not elsewhere classified
  • J84.114 Acute interstitial pneumonitis
  • J84.89 Other specified interstitial pulmonary disease

If the medical record shows an acute lung injury, but does not provide a more specific condition like bronchitis, pneumonitis or the other examples in the code list above, then the supplement instructs you to use unspecified code J68.9 Unspecified respiratory condition due to chemicals, gases, fumes, and vapors.

Coding for toxic effect and poisoning

EVALI is not the only reason you may see a patient in relation to e-cigarettes or vaping. Toxicity from acute nicotine exposure is another issue that physicians have encountered. For instance, patients may have swallowed or breathed in e-cigarette liquid. Absorption through the skin or eyes is also possible.

For patient encounters related to acute nicotine toxicity caused by e-cigarettes, the supplement points you to “other tobacco and nicotine” subcategory T65.291- Toxic effect of other tobacco and nicotine, accidental (unintentional).

If the case instead involves acute tetrahydrocannabinol toxicity, the supplement states you should assign a code from T40.7X1- Poisoning by cannabis (derivatives), accidental (unintentional).

Both of these subcategories require a 7th character to complete the code, making it reportable. Payors will not accept an incomplete code. You’ll choose the 7th character based on whether the encounter meets the ICD-10 definition of initial (7th character A), subsequent (7th character D) or sequela (7th character S).

Check cause: The descriptors for both code subcategories specify “accidental (unintentional).” These codes also apply when the reason for the toxicity or poisoning is not otherwise specified, according to subcategory notes in the ICD-10 Tabular List. The supplement does not address other scenarios directly, but if a different reason for the toxicity is documented, such as intentional self-harm or assault, you should assign the ICD-10 code that reflects the documentation.

Coding for substance use, abuse, and dependence

To report nicotine or cannabis use, abuse, or dependence documented in the medical record, you should follow ICD-10 Official Guidelines, Section I.C.5.b.2, regarding which code to choose. The supplement includes this hierarchy, as well.

Hierarchy for ICD-10-CM reporting of documented use, abuse, dependence (single substance)

If the documentation includes …

Assign the code for …

Use and abuse

Abuse

Abuse and dependence

Dependence

Use, abuse and dependence

Dependence

Use and dependence

Dependence

More than one code may be appropriate if more than one substance is involved. The supplement provides the example of using a code from both F12.- Cannabis related disorders and F17.- Nicotine dependence if there is documentation to support both.

Some physicians and coders have wondered which F17.- codes are appropriate for e-cigarettes. The supplement indicates you should use codes from “other” subcategory F17.29- Nicotine dependence, other tobacco product, adding that “electronic nicotine delivery systems (ENDS) are non-combustible tobacco products.”

To complete the F17.29- codes, you will need a 6th character from this list:

  • 1, uncomplicated
  • 2, in remission
  • 3, with withdrawal
  • 8, with other nicotine-induced disorders
  • 9, with unspecified nicotine-induced disorders

Coding for signs and symptoms

In those cases where these is not a definitive diagnosis, physician claims should report the patient’s signs and symptoms. The supplement provides about 20 examples, including R06.2 Wheezing, R09.02 Hypoxemia, and R53.83 Other fatigue.

A wide variety of signs and symptoms may present during encounters related to e-cigarette use. You should assign ICD-10 codes based on the documentation and in compliance with coding guidelines.

Watch for additional vaping coding news

You may see changes to this vaping coding guidance as more clinical information becomes available, the supplement states. It also reveals that “new codes that are intended to address additional detail regarding use of e-cigarette, or vaping, products will be presented at the March 2020 ICD-10 Coordination and Maintenance Committee Meeting.” If the new codes are adopted, watch for changes to the vaping coding guidelines, as well.

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