COPD: Frequently Used, Frequently Misreported
By Jill M. Young, CPC, CEDC, CIMC
Chronic obstructive pulmonary disease (COPD) is a progressive disease that causes coughing, wheezing, shortness of breath, chest tightness, and other symptoms. The leading cause of COPD is smoking; most people who smoke, or have smoked, have some form of COPD. In 2007, an estimated 12.1 million Americans had the disease, which is not only a major cause of disability but also the fourth leading cause of death in America.
Coders will encounter COPD frequently in medical documentation, but often without the specificity required to code the condition appropriately. A little physician education will go a long way to solve this problem.
Be Cautious of Shortcuts
As coders, we become so familiar with certain anagrams that we memorize the corresponding diagnosis code—HTN for hypertension (401.9 Essential hypertension; Unspecified), DM for diabetes mellitus (250.00 Diabetes mellitus without mention of complication; type II or unspecified type, not state as uncontrolled), and OA for osteoarthritis (715.98 Osteoarthritis, unspecified whether generalized or localized; Other specified sites), to name just a few. Although you may know what ICD-9-CM codes to assign in such cases, you do a disservice to providers if you allow them to document with such nonspecific code assignments. Ensure accurate representation of the patient’s illness by looking at the specificity available to diseases such as COPD.
“COPD” may be written in the record, but that does not give essential details about the patient’s condition, and this leads to coding quandaries. Was the patient ill at this encounter with another respiratory process? Was this illness and its severity included in the record documentation? This information is necessary if you are to select codes that accurately identify the patient’s condition.
COPD 496 Is a Non-Specific Code
Code 496 Chronic airway obstruction not elsewhere classified is one of the few valid three-digit codes in the ICD-9-CM manual. The code includes a subcategory listing of “chronic obstructive pulmonary disease (COPD) NOS,” and is both a not otherwise specified (NOS) and not elsewhere classified (NEC) diagnosis. In other words, 496 is a legitimate diagnosis, but it lacks specificity. Providers like to write the short anagram “COPD” when there may be (and perhaps should be) a more specific code for a patient encounter.
Fold COPD into 491-493, When Present
You should not report 496 with chronic bronchitis (491.xx), emphysema (492.x), or asthma (493.xx), according to ICD-9-CM instructions. Just as shortness of breath normally should be integrated in the coding for pneumonia, COPD should be incorporated into categories 491-493 for the other lung diseases listed.
For example, when COPD is documented with other specified conditions, such as an acute exacerbation (491.21 Obstructive chronic bronchitis) or asthma (493.2x), per coding guidelines, code 496 is not used. In such a case, COPD should not be documented separately because it is redundant to the more-inclusive diagnosis. Nor should you report 496 with 491.0 Simple chronic bronchitis, 492.8 Other emphysemia, or asthma of any kind (493.xx).
A tip in ICD-9-CM 2011 reminds, “COPD is a nonspecific term that encompasses many different respiratory conditions. Review medical record and query physician for more specific documentation of emphysema, bronchitis, asthma, etc.”
One useful tool is the Venn diagram, as shown in Figure A. Similar to what appears in the ICD-9-CM manual, this diagram shows the interrelationship between chronic bronchitis (491.xx), asthma (493.xx), and emphysema (492). The overlapping areas are indicative of diagnoses with shared qualities of two or all three of the major disease processes. As you can see, COPD has attributes of both chronic bronchitis and emphysema; how much of each changes with every patient, and potentially with each encounter.
Tip: As a note of caution, not all physicians agree with the classifications this diagram offers, so you may want to have a discussion with your provider to avoid any confusion.
The Venn diagram helps us to understand that these are three different and distinct diagnoses, but there are related disease processes that must be considered. Your code book may have definitions listed in several of the subsections that are very helpful in differentiating codes with common characteristics. Coding tips from the 2011 ICD-9-CM book specifically state, “Due to the overlapping nature of conditions that make up COPD, it is essential that the coder review all instructional notes carefully.”
For example, documentation of a patient visit may end with the physician listing COPD and chronic bronchitis. This should be coded to 491.0; the chronic bronchitis is the more specific code to the COPD, according to ICD-9-CM guidelines. The same guidelines are applied if the documentation was COPD and asthma. In this example, it is particularly difficult to omit the 496 COPD code because an unspecified code for the asthma is indicated with an unspecified subclassification, which codes to 493.90 Asthma, unspecified; unspecified.
ICD-10 Raises the Stakes
COPD documentation and specificity will become even more important with ICD-10-CM. COPD is classified with acute lower respiratory infections (also identifying the infection), and with exacerbation. You also are instructed, where applicable, to use additional codes to identify exposure to tobacco. This exposure is identified in codes representative of environmental tobacco smoke, history of tobacco use, occupational exposure to environmental tobacco smoke, tobacco dependence, and tobacco use.
Help Providers, Help You
How can coders educate providers to document all the necessary information to code COPD accurately? I recommend you take your code book to providers (or, copy and send them the relevant pages) to show them firsthand the ICD-9-CM guidelines. If a physician sees, for example, there are separate codes for a patient with or without COPD and acute bronchitis, chronic bronchitis, or acute and chronic bronchitis together, they will better understand why you are asking for more specificity. Remind the provider that you cannot code what is not documented. Any dialog between coders and providers is invaluable to producing detailed documentation that leads to code selection with the best-possible specificity.
The next time you see COPD (or 496) listed as a diagnosis, think of the prevalence of patients with this disease process, and remember that this code lacks specificity. Don’t forget there are 24 distinct ICD-9-CM code listings for which COPD should not be listed separately as a diagnosis, according to guidelines. Look to the documentation and your provider for the data needed to represent the patient encounter accurately, with the greatest specificity that the ICD-9-CM system offers.
Jill M. Young, CPC, CEDC, CIMC, has more than 30 years of medical experience working in all areas of the medical practice including clinical, billing, and rounding with physicians. She is the principal of Young Medical Consulting, LLC, and is the current chair of the AAPC Chapter Association (AAPCCA).