International Classification of Diseases, Tenth Revision, Clinical Modification for the Pulmonary, Critical Care, and Sleep Physician.

After a patient encounter, the physician uses two coding systems to bill for the service rendered to the patient. The Current Procedural Terminology (CPT) code is used to describe the encounter or procedure. The International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code is used to describe the diagnosis(es) of the patient. On October 1, 2015, ICD-9-CM coding will end, and all physicians will be required to use a new diagnostic coding system, the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM). This article describes the new diagnostic coding system and how it differs from the old system. There are resources and costs involved for physicians and physician practices to prepare properly for ICD-10-CM. Similar to other important events, the more thorough the preparation, the more likely a positive outcome will occur. Resource use is very important in preparation for the transition from ICD-9-CM to ICD-10-CM. Greater familiarity with ICD-10-CM plus a thorough, effective preparation will lead to reduced costs and a smooth transition. Coding descriptor changes and additional codes occur in ICD-10-CM for chronic bronchitis and emphysema, asthma, and respiratory failure. These changes will affect the coding of these diseases and disorders by physicians. Because the number of codes will increase more than fivefold, the complexity of documentation to support ICD-10-CM will increase substantially. The documentation in the patient's chart to support the ICD-10-CM codes used will need to be enhanced. The requirement for accurate and comprehensive documentation cannot be emphasized enough. All of the coding and documentation changes will be a challenge to pulmonary, critical care, and sleep physicians. They must be prepared fully when ICD-10-CM coding begins and ICD-9-CM coding stops abruptly on October 1, 2015.

An official ATS clinical practice guideline: interpretation of exhaled nitric oxide levels (FENO) for clinical applications.

BACKGROUND: Measurement of fractional nitric oxide (NO) concentration in exhaled breath (Fe(NO)) is a quantitative, noninvasive, simple, and safe method of measuring airway inflammation that provides a complementary tool to other ways of assessing airways disease, including asthma. While Fe(NO) measurement has been standardized, there is currently no reference guideline for practicing health care providers to guide them in the appropriate use and interpretation of Fe(NO) in clinical practice. PURPOSE: To develop evidence-based guidelines for the interpretation of Fe(NO) measurements that incorporate evidence that has accumulated over the past decade. METHODS: We created a multidisciplinary committee with expertise in the clinical care, clinical science, or basic science of airway disease and/or NO. The committee identified important clinical questions, synthesized the evidence, and formulated recommendations. Recommendations were developed using pragmatic systematic reviews of the literature and the GRADE approach. RESULTS: The evidence related to the use of Fe(NO) measurements is reviewed and clinical practice recommendations are provided. CONCLUSIONS: In the setting of chronic inflammatory airway disease including asthma, conventional tests such as FEV(1) reversibility or provocation tests are only indirectly associated with airway inflammation. Fe(NO) offers added advantages for patient care including, but not limited to (1) detecting of eosinophilic airway inflammation, (2) determining the likelihood of corticosteroid responsiveness, (3) monitoring of airway inflammation to determine the potential need for corticosteroid, and (4) unmasking of otherwise unsuspected nonadherence to corticosteroid therapy.

The carbon monoxide diffusing capacity: clinical implications, coding, and documentation.

The test for the diffusing capacity of the lung for carbon monoxide (DLCO) has been available for nearly 100 years for research and clinical purposes. The single-breath method is used almost exclusively in the United States It has been available in clinical pulmonary function laboratories for > 50 years. DLCO has great value in evaluating patients with lung diseases. Guidelines to standardize DLCO have been published by the American Thoracic Society and European Respiratory Society to reduce the interlaboratory variability that has existed. One code, 94720, should be reported for the billing for DLCO. Another code, 94725, the membrane diffusing capacity, exists for the measurement of the membrane and blood components of the DLCO. Currently, no clinical indications exist for the use of the membrane diffusing capacity. The finding that the number of tests in the Medicare population coded with 94725 has increased by > 1,000% from 2000 to 2005 is quite surprising. This rate is 14-times higher than the rate of increase in the utilization of 94720 over the same period. The possible reasons for these increases are discussed, but the most likely explanation is the financial gain derived from coding 94725. It is proposed that coding and billing of 94725 be stopped until the clinical indications for membrane diffusing capacity have been established. Those who code and bill for 94725 must be prepared to justify the use of this code to Medicare and third-party payers.

Granulomatous Pneumocystis carinii pneumonia complicating hematopoietic cell transplantation.

Pneumocystis carinii pneunonia (PCP) is associated with a wide spectrum of clinical and histopathological presentations. While granulomatous PCP uncommonly occurs in AIDS patients, it is extremely rare in other non-AIDS immunocompromised patients. We identified three patients who developed granulomatous PCP after bone marrow or blood stem cell transplantation. In all cases, fiberoptic bronchoscopy with bronchoalveolar lavage was non-diagnostic, and an open lung biopsy was required for diagnosis. All patients were successfully treated with trimethoprim-sulfamethoxazole. The histological appearance varied from an ill-defined granulomatous pneumonia to well-formed necrotizing granulomas. The typical intraalveolar eosinophilic frothy exudate was absent. Often sparsely distributed, the organisms were detected by GMS and immunohistochemical stains for P. carinii. No other pathogens were identified by additional histochemical stains or by microbiological cultures. Awareness of this unusual granulomatous tissue response to P. carinii and initiation of specific treatment can lead to successful resolution of this potentially lethal infection.

Asthma as a consequence of bone marrow transplantation.

Atopy, allergy, or asthma rarely can complicate organ transplantation. We identified two patients who developed asthma following bone marrow transplantation. Neither patient had a documented history of allergy, atopy, or asthma, but their donors were human leukocyte antigen-identical siblings who had a history of asthma. Pulmonary function testing revealed decreased airflow. Investigation of the bronchial biopsy specimens revealed eosinophilia and histologic features that were compatible with asthma. No infectious pathogens were identified. Both patients received therapy with bronchodilators and inhaled corticosteroids with symptomatic improvement. A diagnosis of asthma should be entertained in the differential diagnosis of pulmonary complications in bone marrow transplant recipients.