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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