Coding, Reporting and Documentation Guidance for Postacute Facilities

Coding, Reporting and Documentation Guidance for Postacute Facilities Ingenix is committed to providing our customers with the most current information necessary to meet the challenges of coding, documentation, and reporting postacute health care services. Updates and regulatory changes for the various facilities that provide postacute health care occur at different times during the calendar year. Ingenix will provide free of charge information concerning important changes that are adopted after this product has been published. Just check back regularly at www.shopingenix.com/productalerts to review the latest information concerning regulatory changes. 2010

Chapter 3: OASIS The outcome and assessment information set known as OASIS, developed by the Center for Health Policy Research, is a group of data elements that represent core items of a comprehensive assessment for adult home care patients. These data elements form the basis for measuring patient outcomes for the purposes of quality measurement and improvement, and patient risk factors. OASIS provides: Patient assessment and care planning for individual adult patients HHA level case-mix reports that contain aggregate patient statistics Internal HHA performance improvement OASIS data elements include sociological, demographic, environmental, and support system factors, health status, functional status, and selected attributes of health service utilization. These data elements are intended for adult nonmaternity patients. OASIS measures changes in a patient s health status between two or more defined time points. While many of these data elements are components of a comprehensive assessment, OASIS was not developed or intended to be a comprehensive assessment tool. A comprehensive assessment should include items not included in OASIS, such as vital signs. Medicare HHA conditions of participation include compliance with collection and transmission requirements of the outcome and assessment information set known as OASIS. The use, collection, and transmission of OASIS data is mandatory for all Medicare and Medicaid patients receiving skilled services. CMS intended to have Medicare-approved HHAs collect OASIS data on all patients. Legislation has since delayed the requirement for gathering OASIS data on non-medicare and non-medicaid patients, and the gathering of data on all patients receiving only personal care services. OASIS data must also be provided to the HHA s state survey agency. Generally, agencies excluded from the home health conditions of participations OASIS submission requirement do not receive Medicare payments as they either do not provide services to Medicare beneficiaries or the patients are not receiving Medicare-covered home health services. Under the conditions of participations, home health agencies are excluded from the OASIS reporting requirement on individual patients if: Those patients are receiving only nonskilled services Neither Medicare nor Medicaid is paying for home health care (patients receiving care under a Medicare or Medicaid Managed Care Plan are not excluded from the OASIS reporting requirement) Those patients are receiving pre- or postpartum services Those patients are under the age of 18 years OASIS data is collected at the start of care, at 60-day follow-up intervals, upon admission to and discharge from inpatient facility, and at discharge. Data must be encoded and submitted via OASIS within 30 days of the assessment. OASIS data is used not only for current payment assignment, but also for quality reporting and for future updates to the payment system. OASIS data is linked with claims data to provide information on resource use, trends, and patient characteristics. Decisions concerning the case-mix model are based on comparisons of OASIS data. CMS analyzed OASIS data linked to claims data for the 2008 final rule which contained proposed major revisions to the payment system. In general, the results of a review of post-pps data showed that health characteristics as measured by the OASIS items were stable or changed little. Exceptions to the general findings were indications that the PPS population included: More postacute and more postsurgical patients More patients who had a recent history of postacute institutional care More patients with a recent change in medical or treatment regimen 2009 Ingenix 9

Chapter 6: HHA Billing Rules HHAs use the UB-04 or 837i electronic transaction set to bill for services rendered under a plan of treatment and for medical and other health services not delivered under a plan of care. HHAs submit the UB-04 in the following situations: If the bill for services furnished under a HH plan of treatment includes at least one visit When medical and other health services are under Part B If the patient (or his or her representative) refuses to request payment on his or her behalf When the beneficiary is an HMO enrollee and there is jurisdiction for processing If the provider is responsible for not filing a timely claim for payment Submission of the UB-04 may be required also in the following no-payment situations even though no utilization is chargeable: The patient is discharged. The patient expires. The home health plan is terminated. The beneficiary is responsible for the HHA not filing a timely claim for payment. To ensure the proper receipt of payment under HHPPS, providers must understand the billing rules for the 60-day episode of care. Episodes are the basis for tracking the claim and ultimately form the basis for payment. An episode requires the creation of the following two bills : The first submission is developed at the beginning of the episode and is called a request for anticipated payment, or RAP. Since the RAP is not a claim, it is not subject to all of the Medicare requirements that pertain to claims. RAPs are not subject to payment floors or interest for delayed processing and cannot be appealed. A RAP is submitted based upon the physician-certified and -signed plan of care. If this is not available at the beginning of the episode, a RAP may be submitted using verbal physician orders or a referral, signed and dated by the physician, that prescribes detailed orders for services to be rendered. When verbal orders are received, they must be recorded in the plan of care and include the patient s condition and the services to be rendered. The plan of care must then be immediately copied and submitted to the physician. A billable visit must be rendered before a RAP is submitted. It is important for providers to prepare and submit the RAP in a timely manner. The RAP opens the episode of care with the Medicare Common Working File (CWF), allowing the provider to claim the beneficiary for the 60-day period. The second and final bill is submitted at the end of the 60-day episode of care (or at HHA discharge if sooner), and provides the detail of all items and services received during the 60-day episode. Any appeal rights for the episode are attached to the final claim submission. The final claim must be submitted within 120 days of the start of the episode of care or 60 days from the payment date of the RAP. If it does not fall within the timelines, the RAP payment is recouped. At this point, the RAP must be rebilled before the claim is paid. The plan of care/certification must be signed by the physician before the final claim for a 60-day episode being submitted to Medicare. RAPS are not required for LUPA claims. 2009 Ingenix 55

Chapter 7: ICD-9-CM Coding and the Home Health Agency Introduction In post-acute care, ICD-9-CM diagnosis coding serves many purposes, including reimbursement, quality improvement, research, and compliance. As in other health care settings, ICD-9-CM codes describe the conditions treated and support the medical necessity of services provided. A home health agency (HHA) provides physician, nursing, and rehabilitative home health care services. Home health care consists of part-time, medically necessary skilled care (e.g., nursing, physical therapy, occupational therapy, and speech-language therapy) that is ordered by a physician. Diagnosis coding in home health care requires coding for the medical conditions for which the patient is receiving home health care and any conditions requiring changes in the patient s home health plan of care or treatment. To qualify for Medicare home health services, the patient must be homebound, under the care of a physician, and need intermittent skilled nursing care, physical/speech therapy, or have a continuing need for occupational therapy. For example: Patient paralyzed from a stroke, confined to a wheelchair Patient recently discharged from a hospital after surgery suffering from pain and weakness, whose physical activities (e.g., getting out of bed, walking stairs) are limited Blind patient who requires assistance to leave home The patient may be considered homebound even if he or she leaves home, provided the absences from the home are infrequent, of short duration, or are to receive health care treatment. Correct diagnosis coding for home health care requires an understanding of the official ICD-9-CM coding guidelines and pertinent coding issues in home health as well as an understanding of how ICD-9-CM diagnosis codes affect home health reimbursement. Diagnosis Coding and Home Health Reimbursement CMS refined and updated the home health prospective payment system (HHPPS) in calendar year 2008. There were a significant number of changes, including a totally new case mix model for episodes that began in 2008. Reimbursement is based on a new grouper consisting of a four-equation case mix model based on 153 home health resource groups (HHRG). The 153 HHRGs are divided into five categories based on the sequence of the episode and the amount of therapy provided. These categories are determined by whether the episode is an early episode (first or second) or late episode (third and subsequent) and the number of therapy visits in the episode (e.g., 0 13 therapy visits, 14 19 visits, 20 or more therapy visits). For example, an early episode with low therapy (fewer than 14 visits) is worth 10 points, and a late episode with high therapy (14 or more therapy visits) is worth 20 points. Under the Medicare HHPPS, a case-mix adjusted payment is made using HHRGs, which are represented as HIPPS codes. HIPPS codes are sets of specific patient attributes called case-mix groups which are used to determine payment. A case-mix diagnosis scores a patient for case-mix group assignment. A case-mix diagnosis may be the primary or other diagnosis, or a manifestation associated with the primary or other diagnosis. Case-mix groups are developed based on utilization patterns and clinical assessment data. HIPPS codes are determined based on Outcome and Assessment Information Set (OASIS) assessments. Grouper software uses specific data elements from the OASIS data set to assign a HIPPS code. Each HIPPS code represents a distinct payment amount. There are 153 case-mix groups and each may be combined with any of the six nonroutine supply (NRS) severity levels and two supply levels, resulting in 1,836 possible HIPPS codes. 2009 Ingenix 95

Chapter 3: Minimum Data Set and Resident Assessment Instrument Prerequisites for coverage under the Medicare SNF (extended care benefit) are the patient s need for and receipt of a skilled level of care and the reasonableness and necessity of all services to diagnose or treat the beneficiary s condition. The SNF must determine this by collecting data identified in a minimum data set (MDS) and completing a full assessment of the patient s clinical characteristics and care needs. The Centers for Medicare and Medicaid Services provided a form called the resident assessment instrument, or RAI, to complete when assessing a patient. The minimum data set (MDS) is a defined set of data used in an extended care setting to complete a resident assessment instrument (RAI). The MDS contains more than 400 data elements, including diagnoses, syndromes, signs, symptoms, and treatments. Additionally, the MDS contains information on the patient s mental and physical condition, social environment, and ability to perform the activities of daily living. Physician orders are also considered. The RAI consists of the MDS, resident assessment protocols (RAPs), and utilization guidelines. RAPs are problem-oriented assessments of resident-specific medical problems that form the basis for an individual care plan. Triggers are specific responses to MDS items that identify residents at risk for developing specific problems and require further evaluation using RAPs. The triggers target conditions for additional assessment and review, and the RAP guidelines help facilities evaluate triggered conditions. RAPs are structured, problem-oriented frameworks for organizing MDS information and examining additional clinically relevant information about a resident. RAPs identify social, medical, and psychological problems and are the basis for individual care plans. Specific responses for one or a combination of MDS elements can trigger a warning that a patient has developed or is at risk for developing a specific functional problem. The trigger indicates that further evaluation is required. Triggered RAPs are analyzed using the utilization guidelines provided. SNF staff then decide how to proceed in care planning. RAPs are not required for Medicare assessments, but they are required for comprehensive clinical assessments. Comprehensive clinical assessments are the admission and annual assessments, significant change in status assessment, and the significant correction of a prior full assessment. RAPS must be completed for Medicare assessments when the Medicare assessment is combined with a comprehensive clinical assessment. RAPs may be used at any time the facility wishes to provide an in-depth focused review. SNFs currently use the version 2.0 of the MDS 2.0 and RAI for a comprehensive assessment of each resident s functional capabilities and for reimbursement under the prospective payment system for Medicare. A revised MDS, version 3.0, has been in development. CMS anticipates that the MDS 3.0 will be implemented in fiscal 2010. Version 3.0 is intended to make the data more clinically relevant; improve ease of use, efficiency, and accuracy; integrate selected standard scales; and incorporate the resident s voice through interview questions. Additional information concerning MDS 3.0 may be viewed at the following website: http://www.cms.hhs.gov/nursinghomequalityinits/ 25_NHQIMDS30.asp. All extended care facilities certified as Medicare or Medicaid providers must complete, record, encode, and transmit the MDS for all residents, regardless of the age, diagnosis, length of stay, or payment category. Failure to complete and transmit the MDS will be considered noncompliance with a Medicare and/or Medicaid requirement of participation and may result in an enforcement action. MDS requirements do not apply in the following situations: The extended care facility does not participate in either Medicare or Medicaid. Note that some states 2009 Ingenix 157

Chapter 4: Prospective Payment System Medicare reimburses SNF services under a prospective payment system (PPS). The SNF PPS uses federal per diem payment rates based on mean SNF costs in a base year updated for inflation to the first effective period of the PPS. The original federal payment rates were developed using allowable costs from hospital-based and freestanding SNF cost reports for reporting periods beginning in fiscal year (FY) 1995. These costs were then updated to the first effective year of the PPS (the 15-month period beginning July 1, 1998) using a SNF market basket index, and then standardized for the costs of facility differences in case-mix and for geographic variations in wages. The fiscal 2009 SNF PPS unadjusted federal per diem rates are: Nursing case mix Therapy case mix Therapy non-case mix Regulations required CMS to establish a SNF market basket index that reflects changes over time in the prices of an appropriate mix of goods and services included in covered SNF services. The SNF market basket index is used to update the federal rates on an annual basis. The labor-related portion of the federal rate is wage-adjusted to reflect differences in area wage levels. Hospital wage data is used to wage adjust SNF payments. SNF PPS does not use the hospital area wage index s occupational mix adjustment. For fiscal 2007, the labor-related portion was 75.839 percent. In fiscal 2008, the labor portion was 70.249 percent with fiscal 2009 ending up to be 69.783. The SNF PPS proposed rule for fiscal 2010 had a labor portion of 70.017 percent. The federal rate is adjusted using a case-mix methodology. Non-case mix Urban $151.74 $114.30 $15.05 $77.44 Rural $144.978 $131.80 $16.08 $78.87 A case-mix methodology adjusts payment rates based on the patient s condition (e.g., diagnosis, clinical factors and corresponding resource needs, such as functional factors and service needs). Under SNF PPS, SNFs receive per diem payments for each admission, which are adjusted using a case-mix classification system called resource utilization groups (RUG). A case-mix adjusted payment for SNF care is made using one of 53 RUGs, version III (RUG-III). In a case mix adjusted payment system the amount of reimbursement to the SNF is based on the amount and level of resources required by the resident. The RUG-III classification system uses information from the MDS to classify residents into groups representing their resource requirements. Reimbursement levels differ based on the resource needs of the residents. Payment would be higher for residents whose needs require more staff resources than it would be for those residents with less intensive care needs. For example, a resident that requires more specialized nursing services and licensed therapies is assigned to higher groups in the RUG-III classification and is reimbursed on a higher level. RUG-III grouping is based on data from MDS 2.0 and relative weights developed based on staff time. Patients are classified into RUG-III groups based on need for therapy (i.e., physical, occupational, or speech therapy), special treatments (e.g., tube feeding), and functional status (e.g., ability to feed self and use the toilet). RUG-III grouping is updated periodically based on the patient s status. The RUG-III classification is divided into seven major categories: rehabilitation, extensive services, special care, clinically complex, impaired cognition, behavior problems, and reduced physical function. A completed Minimum Data Set (MDS) will generate a RUG-III score when the information is processed through grouper software. SNF PPS regulations state that a SNF must bill Medicare based on a RUG-III group. Reimbursement is based on the specific RUG-III group coded on a claim (as reported by a Health Insurance Prospective Payment System (HIPPS) code). Grouper software uses specific data elements from the MDS to assign beneficiaries to a RUG-III code. The Grouper outputs the RUG-III code, which must 2009 Ingenix 159

Chapter 6: Other Than Part A Claims There are three situations in which a SNF may submit a claim for services under Medicare Part B. Note that the patient must be enrolled in Medicare Part B insurance with an effective date on or prior to the date of service. If the patient does not have Part B, no claim is submitted. The first situation is when the patient is at a skilled level of care and either does not have or has exhausted Part A benefits, or the patient did not met the three-day qualifying hospital stay or transfer requirements. These services are billed as type of bill 022X. When no Part A payment is possible the medically necessary service or items listed in the table below can be billed as covered ancillary services on a 22X claim. All coverage and billing rules apply. The second situation is a patient who is not in the skilled unit or receives only outpatient services. These services are billed as type of bill 023X. When no Part A payment is possible and for outpatients, the medically necessary service or items listed in the table below can be billed as covered ancillary services. All coverage and billing rules apply. Service Diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests X-ray, radium, and radioactive isotope therapy including materials and services of technicians Surgical dressings, and splints, casts, and other devices used for reduction of fractures and dislocations Revenue Codes 030X, 031X, 032X, 034X, 035X, 040X, 046X, 048X, 061X, 073X, 074X, 075X 0333, 034X 0271, 0272, 0274, 0623 Service Prosthetic devices (other than dental) that replace all or part of an internal body organ (including contiguous tissue), or all or part of the function of a permanently inoperative or malfunctioning internal body organ, including the replacement or repair of such devices Leg, arm, back, and neck braces; trusses; and artificial arms, legs, and eyes, including adjustments repairs and replacements required because of breakage, wear, loss or a change in the patient s physical condition Outpatient physical, occupational, or speech-language pathology therapy 0274 0274 042X, 043X, 044X Screening mammography services 0403 Screening Pap smears 0311, 0923 Influenza virus and its administration, 0771, 0636 pneumococcal vaccine, and its administration Colorectal screening 030X, 032X, 034X Bone mass measurement 0320 Diabetes self-management, smoking 0942 and tobacco-use cessation counseling Prostate screening 0770, 030X Ambulance services 0540 Hemophilia clotting factors for 0636 patients competent to use these factors without supervision Immunosuppressive drugs 0636 Oral anticancer drugs and oral 0636 antiemetics used as a part of the chemotherapeutic regimen Epoetin alfa (EPO) 0636 Revenue Codes 2009 Ingenix 179

Chapter 4: Hospice Reimbursement Hospices furnish services to the extent specified by the plan of care for the patient. Hospices are paid a fixed rate based on the number of days and level of care provided during the election period. Levels of care are: Routine home care Continuous home care (CHC) Inpatient respite care General inpatient care These categories tie to revenue codes and are used to describe the acuity of the service. All services except for CHC are paid at a per diem rate. For CHC, the per diem rate is divided by 24 hours to produce an hourly rate. Respite care is reimbursed at an inpatient respite care per diem for the allowable five days. If an inpatient respite care stay exceeds five days, then subsequent days are paid at the routine hospice care per diem rate. In counting the five days, the date of admission is counted as a day, but the date of discharge is not counted as a day. For the date of discharge from an inpatient unit, the appropriate home care rate is paid unless the patient expires during an inpatient stay. When the patient expires during an inpatient stay, the inpatient rate is paid for the discharge date/date of death. Hospice rates are updated and published annually. Each rate has a portion allocated for labor or wages and a portion for non-labor services. Similar to other Medicare facility payments, the portion allocated to wages is adjusted by a wage index specific to the hospice locality. This wage adjustment is intended to adjust the payment rate to provide for regional differences in wages. Wage Adjustments CMS performs wage adjustments to the labor portion of the payment rate to account for regional differences in wages and salaries paid. The agency uses the most recent pre-floor, pre-reclassified hospital wage index to derive the hospice wage index. IPPS geographic reclassifications are not taken into consideration. The hospice wage indexes follow the Office of Management and Budget designations of rural or urban. The determination of the hospice wage area is based solely on the core-based statistical area (CBSA) designation. The original hospice wage index was based on the 1981 Bureau of Labor Statistics hospital data and had not been updated since 1983. In 1995, a decision was made to update the hospice wage index using a hospital wage index rather than continuing to use the Bureau of Labor Statistics data. It was also decided that for each year in updating the hospice wage index, aggregate Medicare payments to hospices would remain budget neutral to payments as if the 1983 wage index had been used. CMS applies a budget neutrality adjustment factor (BNAF) to ensure that hospice estimated aggregate payments in a given year do not exceed the estimated payments that would have been made had the 1983 hospice wage index values remained in effect. The BNAF is applied to the pre-floor, pre-reclassified hospital wage index to derive the hospice wage index. Estimated payments for fiscal 2010 were made using fiscal 2007 hospice claims data and applying the estimated fiscal 2010 hospice payment rates (updating the fiscal 2009 rates by the fiscal 2010 estimated hospital market basket update). The fiscal 2010 hospice wage index values are then applied to the labor portion of the payment rates only. The procedure is repeated using the same claims data and payment rates but using the 1983 BLS-based wage index instead of the updated raw pre-floor, pre-reclassified hospital wage index. The total payments are then compared, and the adjustment (or BNAF) required to make total payments equal is computed. For routine and CHC, the wage index used is the one that correspond to the actual location or place of service, e.g. the patient s home. For general and respite inpatient care, the wage index used is the one that corresponds to the location of the hospice agency. The hospice wage index is published annually and is effective for the identified fiscal year beginning on October 1 of the year and continuing through 2009 Ingenix 321

Chapter 2: Medicare IRF Requirements The secretary of Health and Human Services has the discretion to define an IRF. Hospitals and exempt units meeting these criteria are eligible to be paid under the IRF PPS. CMS regional offices make the determination that a facility can be classified as an IRF. This decision applies to the entire cost reporting period for which the determination is made. An IRF that has already been excluded from the acute care hospital PPS is always subject to verification that it continues to meet the criteria necessary to allow the facility to be excluded from the acute care hospital PPS. The results of that verification procedure are used in determining each facility's classification status for the next cost reporting period. If a facility fails to meet the criteria necessary to be classified as an IRF, but meets the criteria to be classified as an acute care hospital or acute care hospital unit, it may be paid under the acute care hospital PPS. For the services furnished to a patient who was admitted when the facility was classified as an IRF, but who is discharged after the facility is no longer classified as an IRF, payment to the facility will be from the applicable payment system the facility is paid under when the facility is no longer classified as an IRF. The IRFs that have already been excluded from the acute care hospital PPS do not need to reapply to be classified as an IRF. However, on an annual basis an IRF must self-attest that it still meets the criteria for being classified as an IRF. The Medicare contractor is always required to verify that an IRF has met the criteria specified below in 140.1.1B. The facility must have approval from the RO and the state agency prior to making changes in operations. All IRFs are notified by letter by the appropriate CMS RO of the self-attestation procedures, and other procedures and requirements that apply to them. The FI is not responsible for monitoring or enforcing IRF self-attestation procedures. Criteria That Must Be Met by Inpatient Rehabilitation Hospitals List of Medical Conditions Stroke Spinal cord injury Congenital deformity Amputation Major multiple trauma Fracture of femur (hip fracture) Brain injury. Neurological disorders, including multiple sclerosis, motor neuron diseases, polyneuropathy, muscular dystrophy, and Parkinson s disease Burns Active, polyarticular rheumatoid arthritis, psoriatic arthritis, and seronegative arthropathies resulting in significant functional impairment of ambulation and other activities of daily living that have not improved after an appropriate, aggressive, and sustained course of outpatient therapy services or services in other less intensive rehabilitation settings immediately preceding the inpatient rehabilitation admission or that result from a systemic disease activation immediately before admission, but have the potential to improve with more intensive rehabilitation. Systemic vasculidities with joint inflammation, resulting in significant functional impairment of ambulation and other activities of daily living that have not improved after an appropriate, aggressive, and sustained course of outpatient therapy services or services in other less intensive rehabilitation settings immediately preceding the inpatient rehabilitation admission or that result from a systemic disease activation immediately before admission, but have the potential to improve with more intensive rehabilitation. Severe or advanced osteoarthritis (osteoarthrosis or degenerative joint disease) involving two or more major weight bearing joints (elbow, shoulders, hips, or knees, but not counting a joint with a prosthesis) with joint deformity and substantial loss of range of motion, atrophy of muscles surrounding the joint, significant functional impairment of ambulation and other activities of daily living that have not 2009 Ingenix 379

Coding, Documentation and Reporting for Postacute Facilities subsequent episode of care within eight weeks, assign the fifth digit 2. Rehabilitation Impairment Category: 15 Pulmonary This RIC is used to classify cases in which the major disorder is poor activity tolerance secondary to pulmonary insufficiency. Exercise is a key part of a pulmonary rehab program. to improve the function of the heart and lungs and also strengthen the muscles used for breathing to decrease shortness of breath. Pulmonary rehabilitation programs include medical management, exercise, breathing retraining, education, nutritional counseling, and emotional support. Etiologic Diagnoses: 491.0-491.8 Chronic bronchitis 492.0-492.8 Emphysema 493.00-493.92 Asthma 494.0-494.1 Bronchiectasis 496 Chronic obstructive pulmonary disease (COPD), not elsewhere classified ICD-9-CM Coding Guidelines Chronic Bronchitis Chronic bronchitis is defined as a persistent cough with sputum production occurring on most days for at least three months of the year for at least two years. Obstructive chronic bronchitis is chronic bronchitis combined with obstructive lung disease. Assign a fifth digit 0 to indicate obstructive chronic bronchitis without mention of acute exacerbation and fifth digit 1 for obstructive chronic bronchitis with acute exacerbation. Acute exacerbation of chronic obstructive bronchitis is not the same as acute bronchitis. If the medical record states the patient has chronic bronchitis, with or without mention of centrilobular emphysema (blue bloater), use code 491.2x; however, if the documentation indicates COPD with asthmatic bronchitis, assign 493.2x. Emphysema Pulmonary emphysema is a disease characterized by damage to the alveoli (air sacs) of the lungs. Signs and symptoms include wheezing, prolonged exhalation, decreased breath sounds, and a barrel-chested appearance. Common causal factors include smoking and environmental exposures. Emphysema classified to category 492 refers to pulmonary emphysema only. Emphysema stated as with chronic bronchitis or chronic obstructive pulmonary disease is assigned the appropriate code from the 491.20-491.21 range. Asthma Asthma is abnormal narrowing of the airways due to increased responsiveness of the trachea and bronchi to various stimuli. In ICD-9-CM, asthma is classified as extrinsic, intrinsic, chronic obstructive, or unspecified. Chronic obstructive asthma is used to identify obstructive forms of asthma in obstructive lung disease. Status asthmaticus refers to a prolonged, severe asthmatic attack or airway obstruction that is not relieved by bronchodilators. The documentation should specifically state status asthmaticus to support reporting this condition. Two codes are required when a patient is admitted with acute bronchitis and acute exacerbation of asthma, since both conditions are acute. Sequencing depends on the focus of care. Bronchiectasis Bronchiectasis is the dilation of bronchi with mucous production and persistent cough. Mounier-Kuhn syndrome is a form of bronchiectasis. Code choice is determined by whether the patient also presents with acute bronchitis (acute exacerbation). Do not assign code 494.xx to report bronchiectasis as a congenital disorder (748.61) or bronchiectasis in active tuberculosis (011.5). Chronic Airway Obstruction Chronic airway obstruction is a nonspecific condition characterized by a chronic or recurrent reduction in expiratory airflow within the lung. Chronic obstructive pulmonary disease (COPD) and chronic obstructive lung disease (COLD) are the two most common descriptive diagnostic terms assigned to this code category. Do not assign code 496 with any code from categories 491 493. Coding Scenario A patient with severe chronic obstructive asthma with status asthmaticus is admitted to inpatient rehabilitation following hospitalization for acute respiratory insufficiency. Activities such as walking, showering, and carrying heavy loads produce breathlessness despite his current respiratory medications. As a result he needs assistance with most ADLs. 498 2009 Ingenix