ICD-10-CM coding considerations for vaping-induced illnesses

December 3, 2019

CDI Blog - Volume 12, Issue 149

As of October 1, 2019, 1080 cases of respiratory illnesses and 18 deaths brought on by vaping have been reported in the U.S., according to the U.S. Centers for Disease Control and Prevention (CDC). Despite continued research into these cases by the CDC and the U.S. Food and Drug Administration (FDA), the specific cause of these illnesses remains unknown.

The CDC has asked clinicians to immediately report possible cases of e-cigarette-associated lung disease to their local or state health department for further analysis. Coders and clinical documentation integrity (CDI) professionals should familiarize themselves with clinical signs and symptoms of vaping-induced illnesses so they can effectively review these encounters, facilitate proper ICD-10-CM reporting, and query providers to obtain documentation that details the circumstances, suspected causes, and consequences of vaping-induced illnesses.

This broad overview outlines what public health researchers currently know about the e-cigarette epidemic and how vaping-induced illnesses should be documented and reported using ICD-10-CM codes. Further information will be published by the CDC as more research is conducted.

About e-cigarettes

Electronic cigarettes, more commonly referred to as e-cigarettes, are battery-powered devices that heat tetrahydrocannabinol (THC), nicotine, and other chemicals, and turn them into a vapor that can be inhaled. The use of an e-cigarette product is called vaping.

Because e-cigarettes don’t contain tobacco, the vapor they produce has been thought to be less harmful than conventional cigarette smoke. When these products were first approved for use in the U.S. in 2007, they were marketed as a healthier alternative to smoking that could help smokers quit. In 2015, however, the U.S. Preventive Services Task Force reported that evidence is insufficient to recommend e-cigarettes for smoking cessation. Today, the CDC recommends that everyone consider refraining from using vaping products, particularly those containing THC.

Vape solutions can expose users to harmful chemical ingredients such as acetaldehyde, acrolein, and formaldehyde, which have been linked to lung cancer and cardiovascular disease, according to the American Lung Association. Many vape solutions also contain nicotine, which is highly addictive.

Respiratory illnesses and injuries associated with e-cigarette use

The CDC recently reported that 1080 cases of lung illness associated with the use of e-cigarette products have been reported in 48 states and the U.S. Virgin Islands, and 18 people have died from vaping-related respiratory illness. Review their findings here.

Common signs of vaping-related illness include coughing, chest pain, and shortness of breath. Less commonly, patients report nausea, vomiting, diarrhea, fatigue, fever, and weight loss.

The CDC has received sex and age data for 889 reported cases of vaping-related illness. Of these patients:

Eighty-one percent are under 35 years old.
The average age of patients is 23 years and ranges from 13-75 years.
Seventy percent are male.

Among the 578 patients who reported using vaping products in the three months prior to symptom onset, about 78% reported using THC-containing products; 37% reported exclusive use of THC-containing products.

In a report of 53 vaping-related lung injury episodes in Illinois and Wisconsin published in the New England Journal of Medicine (NEJM), a variety of pulmonary illnesses including those listed below were noted in addition to acute lung injury, adult respiratory distress syndrome, and acute respiratory failure:

Acute and subacute hypersensitivity pneumonitis
Acute eosinophilic pneumonia
Chemical pneumonitis,
Lipoid pneumonia
Metal fume fever
Polymer fume fever

Only 17% of patients vaped with nicotine alone; the rest had inhaled a combination of nicotine, THC, and cannabidiol oils.

While a significant number of patients met the systemic inflammatory response syndrome criteria (29% with fever, 64% with tachycardia, 43% with tachypnea, 87% with leukocytosis, most with a left shift), infections were not isolated. Of the 53 reported cases:

36% required noninvasive positive pressure ventilation
32% required mechanical ventilation
31% had an oxygen saturation of less than 88%

Cytopathology showed some lipid-laden macrophages with a predominance of neutrophils. Pathologists performed transbronchial or open lung biopsies and reported a range of findings, including mild and nonspecific inflammation, acute diffuse alveolar damage and foamy macrophages, and interstitial and peribronchiolar granulomatous pneumonitis.

What is causing the outbreak?

Researchers at the CDC suspect that reported cases of vaping-related illness are due to chemical exposure rather than infection; metals from the vaping coils can also be involved, as postulated in the NEJM article.

As part of an ongoing investigation, the FDA’s Center for Tobacco Products has collected more than 150 vaping product samples to test for chemicals, including painkillers, additives, pesticides, poisons, and toxins. The testing “won’t necessarily answer any questions about causality but it’s a starting point and an important piece of the puzzle,” said Mitch Zeller, JD, director of the FDA's Center for Tobacco Products,

Notably, New York state health officials recently reported that they found vitamin E acetate in several cannabis-containing vaping cartridges submitted by patients who sought treatment for a vaping-induced illness. However, no consistent vaping product, substance, or additive has been identified in all laboratory samples tested by the FDA as causal of the vaping-induced lung injury syndrome.

The CDC recommends that people completely refrain from using e-cigarette or vaping products, especially those containing THC, while the investigation is in progress. For more information on the e-cigarette epidemic, see the CDC’s Morbidity and Mortality Weekly Report.

Documentation, coding for vape use and related illnesses

The CDC recently created a case definition that can be used to consistently classify confirmed and probable cases of vaping-related illness in a consistent way. Unlike most reportable conditions, these cases require clinicians to interview patients to determine product use and individual behaviors. State investigators are collaborating with clinical care teams to determine if reported cases are confirmed or probable based on data in the patients’ medical records. The CDC will report updated data on confirmed and probable cases once these reviews are finalized.

When a patient seeks treatment for a vaping-related illness, provider documentation guides what can be coded. Coders must determine if the documentation supports the reporting of use, abuse, or dependence of the substance that was in the cigarette, said Laurie M. Johnson, MS, RHIA, FAHIMA, AHIMA-approved ICD-10-CM/PCS trainer at Revenue Cycle Solutions LLC in Pittsburgh, Pennsylvania.

“If the physician states that the patient is a smoker using e-cigarettes, the ICD-10-CM Index allows the reporting of an ICD-10-CM code from subcategory F17.29- [nicotine dependence, other tobacco product] for the use of e-cigarettes containing nicotine. This, however, does not apply to other substances,” she said.

When a patient develops a physical, mental, or behavioral consequence after vaping THC and the physician explicitly documents that the THC caused the sickness, the coder may report a code from ICD-10-CM subcategory T40.7X1- (poisoning by, adverse effect of and underdosing of cannabis [derivatives], accidental); the seventh character would identify the encounter type (i.e., initial encounter– active treatment [A], subsequent– healing phase [D], or sequela [S]), said Johnston. An additional code based on provider documentation would be used to report whether there was use, abuse (mild cannabis use disorder), or dependence (moderate or severe cannabis use disorder).

Unfortunately, there are no ICD-10-CM reporting guidelines specific to the vaping-related illness being monitored by the CDC. “When a patient presents for treatment of a vaping-related illness, the provider is likely to document one of the following terminologies described in the CDC or NEJM literature,” said James S. Kennedy, MD, CCS, CCDS, CDIP, founder and president of CDIMD, a Nashville-based physician and facility advisory and consulting firm. These include:

Vaping-induced lung injury– non-codable in ICD-10-CM since it is not in the Alphabetic Index

Vaping lung injury syndrome– non-codable in ICD-10-CM since it is not in the Alphabetic Index

Consequently, coders must adhere to the following guidance in the 2020 ICD-10-CM Official Guidelines for Coding and Reporting:

15. Syndromes

Follow the Alphabetic Index guidance when coding syndromes. In the absence of Alphabetic Index guidance, assign codes for the documented manifestations of the syndrome. Additional codes for manifestations that are not an integral part of the disease process may also be assigned when the condition does not have a unique code.

“Coders and CDI professionals must be aware of the pathophysiology associated with the vaping-related lung syndrome to select the correct codes or solicit documentation that best fits the patient’s circumstances,” said Kennedy. The MUSIC mnemonic, provided by Kennedy, can be used as a foundation for critical thinking when determining the correct ICD-10-CM codes for a vaping-induced illness:

Manifestation– What are the signs and symptoms indicative of a vaping-induced illness? These could be dyspnea, hemoptysis, pleuritic chest pain, other chest pain, hypoxemia, fever, leukocytosis, or others.
Underlying cause– What is the pathological origin of the illness?

Inpatient coders and CDI professionals must emphasize that provider documentation of the suspected underlying cause of these manifestations is required at the time of discharge, preferably in the discharge summary, as noted in the ICD-10-CM Official Guidelines for Coding and Reporting:

If the diagnosis documented at the time of discharge is qualified as “probable,” “suspected,” “likely,” “questionable,” “possible,” or “still to be ruled out,” “compatible with,” “consistent with,” or other similar terms indicating uncertainty, code the condition as if it existed or was establishe

Potential underlying causes of the illness based on the analysis of pathological specimens might be:
- J69.1, pneumonitis due to inhalation of oils and essences (exogenous lipoid pneumonia
- J84.89, other specified interstitial pulmonary diseases
- J68.0, bronchitis and pneumonitis due to chemicals, gases, fumes and vapors
- J68.1, pulmonary edema due to chemicals, gases, fumes and vapors
- Whatever the physician thinks that the pathology likely is based on their reading of reputable literature.

Notably, in a correspondence from the Mayo Clinic Arizona reported in the NEJM on October 2, pathologists emphasized that while vaping-induced lung injury has been associated with lipoid pneumonia, none of their cases have showed histologic evidence of exogenous lipoid pneumonia.

They further added, “Although it is difficult to discount the potential role of lipid, we believe that the histologic changes instead suggest that vaping-associated lung injury represents a form of airway-centered chemical pneumonitis from one or more inhaled toxic substances rather than exogenous lipoid pneumonia as such, but the agents responsible remain unknown.”

Given that in many cases the exact pathology of patients with vaping-associated lung injury is unknown, Kennedy strongly recommends that coders and CDI specialists urge physicians to document the suspected or likely pathologies of these patients in the discharge note or summary based on the most current literature so these can be accurately captured in ICD-10-CM administrative databases.

Specificity or severity
- Specify whether reportable conditions are acute or chronic, when applicable.
Instigating causes can include:
- T59.891A, toxic effect of other specified gases, fumes and vapors, accidental (unintentional), initial encounter
Consequences can include:
- J96.01, acute respiratory failure with hypoxia
- J80, acute respiratory distress syndrome
- R04.2, hemoptysis
- R04.89, hemorrhage from other sites in respiratory passages
- R65.10, systemic inflammatory response syndrome (SIRS) of non-infectious origin without acute organ dysfunction
- R65.11, SIRS of non-infectious origin with acute organ dysfunction
- Whatever suspected factors and mechanisms leading to the patient’s death, which should be explicitly documented on the discharge summary.