Don’t Let COPD Diagnosis Coding Be an Endurance Test

Don’t Let COPD Diagnosis Coding Be an Endurance Test

Several conditions fall under COPD; understand how to code them all.

By Gouri Pathare, MBBS, CPC

Chronic obstructive pulmonary disease (COPD) refers to chronic bronchitis, emphysema, and alpha-1 antitrypsin deficiency, a genetic form of emphysema. Diagnosis coding and sequencing for COPD depends on physician documentation in the medical record and application of the official coding guidelines for inpatient care. You also may use American Hospital Association’s AHA Coding Clinic for ICD-9-CM and American Medical Association’s CPT® Assistant references to ensure complete and accurate coding.

Chronic bronchitis and emphysema are two distinct processes, often present in combination with chronic airway obstruction. Chronic bronchitis is associated with excessive tracheobronchial mucus production sufficient to cause cough with expectoration for at least three months of the year, for more than two consecutive years. Emphysema is defined as distension of air spaces distal to the terminal bronchial with destruction of alveolar septa. COPD is defined as a condition in which there is chronic obstruction to airflow due to chronic bronchitis or/and emphysema.

Coding Guidelines

When coding diagnoses of COPD, chronic bronchitis, acute bronchitis, chronic asthmatic bronchitis, acute asthmatic bronchitis, emphysema, etc., it’s important to understand the coding ramifications of the presence of two or more of these conditions, and whether the condition is acute, chronic, or in acute exacerbation.

COPD not elsewhere classified (ICD-9-CM code 496 Chronic airway obstruction, not elsewhere classified) is a nonspecific code that should only be used when the documentation in the medical record does not specify the type of COPD treated.

Acute Bronchitis/Asthma

Acute bronchitis with asthma is coded 466.0 Acute bronchitis and 493.90 Asthma, unspecified type, unspecified. The acute condition is sequenced before a chronic condition. Asthma is not documented as exacerbated, nor is the patient in status asthmaticus (AHA Coding Clinic for ICD-9-CM, fourth quarter 2004).

When coding acute bronchitis (466.0) and an exacerbation of asthma (493.92 Asthma, unspecified type, with (acute) exacerbation), code first the condition requiring the most care, or that is the major focus of care. An infectious process, such as acute bronchitis, is not equivalent to an acute exacerbation of asthma (AHA Coding Clinic for ICD-9-CM, fourth quarter 2004).

COPD with Acute Bronchitis

A diagnosis of COPD and acute bronchitis is classified to 491.22 Obstructive chronic bronchitis with acute bronchitis. It’s not necessary to assign code 466.0 (acute bronchitis) with 491.22. Code 491.22 is also assigned if the physician documents acute bronchitis with COPD exacerbation. If acute bronchitis is not mentioned with the COPD exacerbation, assign 491.21 Obstructive chronic bronchitis with (acute) exacerbation (AHA Coding Clinic for ICD-9-CM, fourth quarter 2008).

Acute Bronchitis/Emphysema/Chronic Obstructive Asthma

Acute bronchitis and emphysema are coded 466.0 and 492.8 Other emphysema. Acute bronchitis and chronic obstructive asthma are coded 466.0 and 493.2x Chronic obstructive asthma (AHA Coding Clinic for ICD-9-CM, volume 10, No. 5, and fourth quarter 1993).

Acute Exacerbation of COPD/ Bronchitis/ Asthma

Diagnoses of acute exacerbation of COPD, acute bronchitis, and acute exacerbation of asthma are coded 491.22 and 493.22 Chronic obstructive asthma with (acute) exacerbation (AHA Coding Clinic for ICD-9-CM, third quarter 2006).

COPD with Asthma

Asthma with COPD is classified to 493.2x.

Codes 493.0x Extrinsic asthma, 493.1x Intrinsic asthma, and 493.9x Asthma unspecified are used to classify asthma in patients without COPD. Be sure to review all coding directives in the Tabular List and Index to ensure appropriate code assignment. A fifth-digit sub classification is needed to identify the presence of status asthmaticus or exacerbation.

Report asthmatic bronchitis not specified as chronic with 493.90.

Bronchospasm

Bronchospasm is considered integral to asthma and COPD. Additional code 519.1x Other diseases of trachea and bronchus not elsewhere classified is not needed (AHA Coding Clinic for ICD-9-CM, third quarter 1988).

Chronic Bronchitis/Emphysema

Emphysema with chronic bronchitis is excluded from 492.8 Other emphysema. Use 491.20-491.22 (AHA Coding Clinic for ICD-9-CM, fourth quarter 2004).

Chronic Obstructive Bronchitis

An acute exacerbation of chronic obstructive bronchitis is coded 491.21 (AHA Coding Clinic for ICD-9-CM, fourth quarter 1991).

Chronic Obstructive Bronchitis/Emphysema/COPD

Chronic obstructive bronchitis and emphysema are forms of COPD. Chronic obstructive bronchitis with COPD and emphysema with COPD are redundant terms. COPD is not a separate disease entity (AHA Coding Clinic for ICD-9-CM, fourth quarter 1993).

Chronic Restrictive Lung Disease

Chronic restrictive lung disease is coded 518.89 Other diseases of lung, not elsewhere classified.

COPD on Anesthesia Evaluation

A diagnosis of COPD for an anesthesia evaluation signed by the anesthesiologist can be coded if there is no conflicting documentation in the medical record and you are certain COPD is a valid diagnosis (AHA Coding Clinic for ICD-9-CM, second quarter 2000 and second quarter 1992).

COPD/Complication of Surgery

If a patient with a history of COPD is admitted as an inpatient following outpatient surgery because of COPD exacerbation due to the procedure, assign 997.3 Respiratory complications not elsewhere classified as the principal diagnosis, with a secondary diagnosis of 491.21 (AHA Coding Clinic for ICD-9-CM, fourth quarter 1993).

Acute exacerbation of COPD (or acute exacerbations of chronic bronchitis) is a sudden worsening of COPD symptoms (shortness of breath, changes in quantity and color of phlegm) typically lasting for several days. Infection with bacteria or viruses or environmental pollutants may trigger acute exacerbation of COPD.

Emphysema/Respiratory Failure

A patient with emphysema is admitted to the hospital for acute respiratory failure. The principal diagnosis is 518.81 Acute respiratory failure (AHA Coding Clinic for ICD-9-CM, first quarter 2005).

Exacerbation of COPD

Exacerbation is defined as a decompensation of a chronic condition. It’s also defined as an increased severity of asthma symptoms, such as wheezing and shortness of breath. Although an infection can trigger it, an exacerbation is not the same as an infection superimposed on a chronic condition.

Status asthmaticus is a continuous obstructive asthmatic state unrelieved after initial therapy measures. If a physician documents both exacerbation and status asthmaticus in the same record, assign the fifth digit “1” to show the status asthmaticus. Sequence the status asthmaticus code first if documented with any type of COPD or with acute bronchitis (AHA Coding Clinic for ICD-9-CM, fourth quarter 2008).

COPD with exacerbation is classified to 491.21, which also includes:

  • Acute exacerbation of COPD
  • Exacerbation of COPD
  • Decompensated COPD
  • Decompensated COPD with exacerbation
  • COPD in exacerbation
  • Severe COPD in exacerbation
  • End-stage COPD in exacerbation

The word “acute” does not need to be documented to assign 491.21 for exacerbation of COPD (AHA Coding Clinic for ICD-9-CM, third quarter 2002). Per AHA Coding Clinic for ICD-9-CM (third quarter 1988), “When the acute exacerbation of COPD is clearly identified, it is the condition that will be designated as the principal diagnosis.”

Acute exacerbation of COPD, acute bronchitis, and acute exacerbation of asthma are classified to 491.22 and 493.22 (AHA Coding Clinic for ICD-9-CM, third quarter 2006).

Exposure to Tobacco Smoke/COPD

A physician’s diagnosis of an acute exacerbation of COPD with bronchitis, secondary to patient’s exposure to tobacco smoke due to 25 years of smoking, is coded 491.21 and 305.1 Tobacco use disorder (AHA Coding Clinic for ICD-9-CM, second quarter 1996).

Mucopurulent Bronchitis

Chronic or recurrent mucopurulent bronchitis is coded 491.1 Mucopurulent chronic bronchitis (AHA Coding Clinic for ICD-9-CM, third quarter 1988). Acute or subacute mucopurulent bronchitis is coded 466.0 (AHA Coding Clinic for ICD-9-CM, third quarter 1988; ICD-9-CM Index to Diseases).

Pneumonia/Asthma/COPD

Chronic obstructive bronchitis (491.20 Obstructive chronic bronchitis without exacerbation) and pneumonia (486 Pneumonia, organism unspecified) are always coded separately. Pneumonia is not an acute exacerbation of COPD (AHA Coding Clinic for ICD-9-CM, third quarter 1997). If  both asthma and pneumonia are present, each should be reported (AHA Coding Clinic for ICD-9-CM, first quarter 1992).

Respiratory Insufficiency/COPD

Respiratory insufficiency (518.82 Other pulmonary insufficiency, not elsewhere classified) is integral to COPD and should not be coded additionally with chronic obstructive bronchitis (491.2x), emphysema (492.x), chronic obstructive asthma (493.2x), or COPD (496) (AHA Coding Clinic for ICD-9-CM, second quarter 1991).

Secondary Diagnosis/COPD

Substantiation of COPD as a secondary diagnosis requires documentation in the medical record (history, treatment, anesthesiologist’s anesthesia evaluation, etc.) that the patient has COPD. Be sure to clarify with the physician any conflicting information (AHA Coding Clinic for ICD-9-CM, third quarter 2007, second quarter 2000, and second quarter 1992).

If the only mention of COPD is on an X-ray, the diagnosis should be clarified with the physician because COPD is found on many elderly patients’ chest X-rays when other clinical substantiation, treatment, or history of COPD is not present (AHA Coding Clinic for ICD-9-CM, second quarter 1990).

Steroid-dependent Asthma

Steroid-dependent asthma is coded to category 493 Asthma when there is no mention of a side effect due to the steroid therapy. When a side effect is mentioned, code both the asthma and the side effect. See Steroid in the ICD-9-CM Index to Diseases and the subentry for effects due to correct substance properly administered, 255.8 Other specified disorders of adrenal glands (AHA Coding Clinic for ICD-9-CM, July-August 1985).

ICD-9 Codes for COPD in Pregnancy

Pre-existing asthma or COPD complicating pregnancy, childbirth, or the puerperium is assigned two codes. First, assign 648.9x Other current conditions complicating pregnancy, childbirth, or the puerperium, followed by the COPD code.

COPD and ICD-10

Other Chronic Obstructive
Pulmonary Disease (COPD)

Includes asthma with COPD:

Chronic bronchitis with airway obstruction

Chronic bronchitis with emphysema

Chronic emphysematous bronchitis

Chronic obstructive asthma

Chronic obstructive bronchitis

Chronic obstructive tracheobronchitis

Code also type of asthma, if applicable (J45.-)

J44.0 Chronic obstructive pulmonary disease with acute lower respiratory infection

Use additional code to identify the infection.

J44.1 Chronic obstructive pulmonary disease with (acute) exacerbation

Decompensated COPD

Decompensated COPD with (acute) exacerbation

Excudes2:
Chronic obstructive pulmonary disease with acute bronchitis J44.0

J44.9 Chronic obstructive pulmonary disease, unspecified

Chronic obstructive airway disease NOS

Chronic obstructive lung disease NOS

J45 Asthma 

Includes:

Allergic (predominantly) asthma

Allergic bronchitis NOS

Allergic rhinitis with asthma

Atopic asthma

Extrinsic allergic asthma

Hay fever with asthma

Idiosyncratic asthma

Intrinsic non allergic asthma

Non allergic asthma

J45.2 Mild intermittent asthma

J45.20 Mild intermittent asthma, uncomplicated

Mild intermittent asthma NOS

J45.21 Mild intermittent asthma with (acute) exacerbation

J45.22 Mild intermittent asthma with status asthmaticus

J45.3 Mild persistent asthma

J45.30 Mild persistent asthma, uncomplicated

Mild persistent asthma NOS

J45.31 Mild persistent asthma with (acute) exacerbation

J45.32 Mild Persistent Asthma with status asthmaticus

J45.4 Moderate persistent asthma

J45.40 Moderate persistent asthma, uncomplicated

Moderate persistent asthma NOS

J45.41
Moderate persistent asthma with (acute) exacerbation

J45.42
Moderate persistent asthma with status asthmaticus

J45.5 Severe persistent asthma

J45.50 Severe persistent asthma, uncomplicated

Severe persistent asthma NOS

J45.51 Severe persistent asthma with (acute) exacerbation

J45.52 Severe persistent asthma with status asthmaticus

J45.9 Other and unspecified asthma

J45.90 Unspecified asthma

J45.901
Unspecified asthma with (acute) exacerbation

J45.902
Unspecified asthma with status asthmaticus

J45.909 Unspecified asthma, uncomplicated

J45.99 Other asthma

J45.990 Exercise induced bronchospasm

J45.991 Cough variant asthma

J45.998 Other asthma

Categories J44 and J45 distinguish between uncomplicated cases and those in acute exacerbation. An acute exacerbation is a worsening or a decompensation of a chronic condition. An acute exacerbation is not equivalent to an infection superimposed on a chronic condition, although an exacerbation may be triggered by an infection.

Assign J44.0 for COPD with acute bronchitis. Report J44.1 for the acute exacerbation of COPD. For acute exacerbation of asthma, report J45.901.


 

Gouri Pathare, MBBS, CPC, is a practicing medical professional with nearly 30 years of experience as an independent private medical practitioner in Mumbai, India, and has worked as a clinical specialist training coders for Episource India Pvt, Ltd., a U.S.-based KPO company.

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Renee Dustman

Renee Dustman

Renee Dustman is executive editor at AAPC. She has a Bachelor of Science degree in Journalism and a long history of writing just about anything for just about every kind of publication there is or ever has been. She’s also worked in production management for print media, and continues to dabble in graphic design.
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Renee Dustman is executive editor at AAPC. She has a Bachelor of Science degree in Journalism and a long history of writing just about anything for just about every kind of publication there is or ever has been. She’s also worked in production management for print media, and continues to dabble in graphic design.

2 Responses to “Don’t Let COPD Diagnosis Coding Be an Endurance Test”

  1. Anthony Chloe says:

    Healing from COPD, i never taught dr.abegbu who could ever get my COPD cured with his healing herbal cures, i have tried almost everything but i couldn’t find any solution on my disease, despite all these happening to me, i always spend a lot to buy a COPD drugs from hospital and taking some several medications but no relieve, until one day i was just browsing on the internet when i come across a great post of ! Williams Fran-ca who truly said that she was been diagnose with COPD and was healed that very week through the help of these great powerful healing doctor, sometime i really wonder why people called him Baba ABEGBU i never knew it was all because of the great and perfect work that he has been doing that is causing all this. so i quickly contacted him, and he ask me some few questions and he said a thing i will never forget that anyone who contacted him, is always getting his or her healing after take the herbs cure in a week so i was amazed all the time i heard that from him, so i did all things only to see that at the very day which he said i will be healed, all the strength that has left me before rush back and i became very strong and healthy, this disease almost kills my life all because of me, so i rush to hospital for the final test. So the disease and the doctor said i am COPD negative, i am very amazed and happy about the healing DR.ABEGBU gave to me from the ancient part of Africa, you can email him now for your own healing too at DR.ABEGBUHEALER@GMAIL.COM or DR.ABEGBUHEALER@outlook.com

  2. john holly says:

    HOW CAN I TELL THIS TO THE WHOLE WORLD My name is john holly i was suffering from COPD disease over 3year ago,i went to different hospitals,they could not solve my problem and i was so hopeless and helpless when i was in the river side thinking of what to do a lady walk to me and said what is the problem and i told her everything,she told me about this great man called OGBIDIKI and gave me his email address and i email him,and him told me that every thing we be alright, and that i should put my trust in him and i did what him said, and he told me what to being and i brought every thing that him told me. in two day later i went to the hospital to do the test of COPD i find out that it was negative,so help me thank the great great OGBIDIKI. if you also have such a problem or a problem that is bigger than that email him with this EMAIL ADDRESS:ogbidikiharbalremendyhome@gmail.com, i will hallway continues to share your testimony. thank you doctor my regard to you and your family.

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