How to Properly Code RSV Bronchiolitis Cases
Explore our in-depth analysis of pediatric bronchiolitis cases, including coding solutions for RSV diagnosis and E/M level selection tailored for optimal billing accuracy.
Pediatric Billing & Coding Alert
One of the most frequently encountered diagnoses by pediatricians during the winter respiratory virus season is bronchiolitis, primarily affecting infants and very young children. This condition is different from bronchitis, which is rarely seen in children and more commonly affects adults. The majority of bronchiolitis cases are caused by respiratory syncytial virus (RSV), although other viruses can present similar clinical symptoms. While RSV can impact individuals of all ages, it poses the greatest risk to the very young and the elderly.
The severity of the illness can vary significantly, ranging from mild nasal congestion to respiratory failure and even death. This broad range of severity complicates the appropriate assignment of evaluation and management (E/M), ICD-10, and CPT testing codes.
To assist you in navigating these complexities, we will explore two scenarios.
Case 1: Evaluation of a 10-Month-Old with Suspected Bronchiolitis
In this scenario, a pediatrician sees a 10-month-old established patient and her mother. The mother reports that the infant has been experiencing nasal congestion, sneezing, and a mild cough for the past three days, along with low-grade fevers. There are no signs of labored breathing, but the infant has shown a slight decrease in appetite. The mother expresses concern due to the high incidence of RSV at the daycare the child attends.
During the physical examination, the child appears alert and comfortable, with no increased work of breathing noted. The pediatrician observes mild bilateral expiratory wheezing and conducts an office RSV test, which returns positive. The pediatrician diagnoses the infant with bronchiolitis caused by RSV and advises the mother on the signs and symptoms of worsening conditions that would necessitate further evaluation. The recommended home treatment includes nasal suctioning and administering Tylenol as needed.
Now, let's proceed to code this encounter.
ICD-10-CM Code Selection for Bronchiolitis Diagnosis
In pediatric practices, some offices perform point-of-care testing for RSV, while others do not. The diagnosis of bronchiolitis can often be established based solely on the patient’s history and physical examination. In such instances, the appropriate diagnosis code to use is J21.9 (Acute bronchiolitis, unspecified). This code should also be reported when a physician tests for RSV and receives a negative result, as the bronchiolitis may be caused by a different virus that was not tested.
However, in this specific case, where the RSV test returns positive, the correct code to assign is J21.0 (Acute bronchiolitis due to respiratory syncytial virus).
E/M Level Selection for Bronchiolitis
In the context of E/M level selection, CPT defines a minimal degree of complexity as a problem that "runs a definite and prescribed course, is transient in nature, and is not likely to permanently alter health status." Given the potential for serious illness and the unpredictable nature of bronchiolitis, no infant with this condition would qualify under this category.
Determining whether the complexity of bronchiolitis is limited or moderate can be challenging; however, this case likely represents an acute uncomplicated illness, indicating low complexity for this element.
The presence of an independent historian and only one additional data point supports the conclusion of limited data in this element.
The treatment involved recommending over-the-counter medication and providing guidance on how to perform nasal suctioning effectively. Therefore, the risk level for this case would be considered low.
Given the assessment of low complexity, limited data, and low risk, the appropriate CPT E/M code for this encounter would be 99213 (Office or another outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using total time on the encounter date for code selection, 20 minutes must be met or exceeded).
ICD-10-CM Codes and E/M Level for Bronchiolitis Diagnosis
|
Test Result |
Diagnosis Code |
Description |
E/M Level and Description |
|
History/Exam Only |
J21.9 |
Acute bronchiolitis, unspecified |
99213: Office visit for established patient; low complexity, limited data, low risk |
|
RSV Test Negative |
J21.9 |
Acute bronchiolitis, unspecified |
99213: Office visit for established patient; low complexity, limited data, low risk |
|
RSV Test Positive |
J21.0 |
Acute bronchiolitis due to respiratory syncytial virus |
99213: Office visit for established patient; low complexity, limited data, low risk |
Case 2: Evaluation of a 10-month-old with Acute Bronchiolitis
In this scenario, a pediatrician examines a 10-month-old established patient accompanied by her mother. The mother reports that the infant has experienced a cough, runny nose, nasal congestion, and low-grade fevers for three days. However, this morning, the child began having difficulty breathing. Additionally, the child has been lethargic and not eating as much as usual. The child's medical history does not reveal any significant issues.
During the physical examination, the pediatrician observed that the child was breathing rapidly and had difficulty breathing. Wheezing and crackles are noted upon chest examination, and the patient's oxygen saturation levels are low. The office RSV test returns positive, and the pediatrician diagnoses the infant with acute bronchiolitis due to RSV.
A documented discussion occurs between the pediatrician and the mother regarding the potential need for hospitalization, with the pediatrician stating, "This baby is on the fence for admission to the hospital." After shared decision-making, they conclude that the infant will return home with close monitoring for any worsening symptoms. A follow-up appointment is arranged for the following day. The pediatrician advises the mother to administer Tylenol as needed and reviews the proper technique for nasal suctioning to alleviate the infant's symptoms.
ICD-10-CM Code Selection for Case 2
For this case, you would start with the same ICD-10-CM code selection of J21.0, as the RSV test is positive. However, this case describes a considerably sicker child who presents with lethargy, difficulty breathing, and low oxygen saturation levels. As a result, hypoxia is also present, which is coded as R09.02 (Hypoxemia). Therefore, in this scenario, the following codes would be assigned:
|
Diagnosis Code |
Description |
|
J21.0 |
Acute bronchiolitis due to respiratory syncytial virus |
|
R09.02 |
Hypoxemia (low oxygen saturation) |
This coding reflects both the primary diagnosis of bronchiolitis due to RSV and the secondary diagnosis of hypoxemia, indicating the severity of the child's condition.
E/M Level Selection for Case 2
In this case, the presence of hypoxia categorizes the situation as an acute illness with systemic symptoms, indicating a moderate level of complexity for the E/M level selection. The documentation from an independent historian, along with only one test ordered, justifies a limited level in the data element.
Regarding the risk element, the documentation notes that the pediatrician discussed the possibility of hospitalizing the infant due to the low oxygen levels. In situations like this, the decision to admit is often influenced by the severity of the oxygen level and the comfort level of both the physician and the family with managing the infant's care at home, given the potential risk for deterioration. Therefore, a high-risk element level is appropriate for this case since hospitalization was a documented consideration.
Based on these assessments, the appropriate CPT® E/M code for case two is 99214 (Office or other outpatient visits for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and a moderate level of medical decision-making. When using total time on the encounter date for code selection, 30 minutes must be met or exceeded), reflecting moderate complexity, limited data, and high risk.
ICD-10-CM Codes and E/M Level for Case 2
|
Diagnosis Code |
Description |
E/M Level and Description |
|
J21.0 |
Acute bronchiolitis due to respiratory syncytial virus |
99214: Office visit for established patient; moderate complexity, limited data, high risk |
|
R09.02 |
Hypoxemia (low oxygen saturation) |
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