Documenting and Coding Bronchitis

Hello everyone and Welcome to our Podcast series. My name is Natalie Tornese and I am a Senior Solutions Manager – Outsource Strategies International. Want to take some time to talk about Bronchitis.

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.

Bronchitis can occur when a virus, bacteria or irritant particles trigger an inflammation of the bronchial tubes. Smoking is a common risk factor for both- chronic bronchitis and acute. Non-smokers however can also develop the condition. In additionally, air pollution, dust or toxic gases in the environment or workplace can also contribute to the condition. Acute bronchitis can also result from a virus, bacterial infection or the exposures that irritate the lungs. Usually improves within 7-10 days without lasting effects, but the cough may linger for a while. Chronic bronchitis, results from the repeated irritation and damage to the lung and airway tissues.

Cough is one of the most common symptoms associated with the condition. It 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 walls well, or even cause a person to faint. Other related symptoms can include – Wheezing, Slight fever and chills, Shortness of breath, Headaches, Fatigue, body aches, Production of mucus (sputum), a sore throat, tightness in the chest, a blocked nose and sinuses.

The signs and symptoms of the condition can be difficult to distinguish during the first few days of illness. In most cases, the symptoms may be similar to those of the common cold. A physician will diagnose you with a physical exam. They will listen to your lungs; they may also conduct a detailed review of your medical history, smoking history, exposure to secondhand smoke, dust, fumes, air pollution. They may take a sputum swab test. They may do a chest X-ray, do some pulmonary lung function tests or blood tests just to check the oxygen levels in the person’s blood, they may recommend that as well.

In most cases, it does get better without treatment, usually within a couple of weeks. Antibiotics and other medications may be recommended for people who suffer from bacterial infections. Physicians may recommend an inhaler and other medications to reduce inflammation and open the narrowed passages in the lungs. Breathing exercise program may be recommended for people with chronic bronchitis.

ICD-10 codes need to be more specific with this condition. I will include a transcript along with this podcast to go over this specific ICD-10 codes. The documentation for bronchitis must include the following criteria –

• The type – should be considered and includes simple, mucopurulent, fibrinous, membranous, purulent, or septic bronchitis
• Temporal factors must be documented
• Infectious agents must be documented along with the associated conditions and causes.

I hope this helps and always remember that proper documentation is keen.

Thank You for Listening.