New guidelines regarding the proper coding of Chronic Obstructive Pulmonary Disease (COPD) added another level of complexity to this common, multifactorial disease. Specifically, when an acute exacerbation of COPD is present with asthma or pneumonia. Acute exacerbation of COPD is a worsening or a decompensation of the chronic condition. Simple enough. But when the acute exacerbation is superimposed with an infection or asthma, the coding gets tricky.

This month’s version of TrustHCS Knowledge Bites provides coders with a few pointers to correctly code COPD, acute exacerbation.

Clarify the Asthma

When the patient’s acute COPD includes a diagnosis of asthma, the type of asthma must be documented and correctly coded. Unspecified asthma with COPD is not acceptable for ICD-10 coding. Also, “an exacerbation of COPD doesn’t automatically make the asthma exacerbated” according to AHA’s Coding Clinic, First Quarter 2017: page 26.

In these cases, coders are advised to obtain additional documentation from the physician regarding the type of asthma present: (intermittent or persistent); acuity of asthma (mild, moderate, severe) and if the asthma was in acute exacerbated or status asthmaticus. The correct codes include:

J45 Asthma
J45.2 Mild intermittent asthma
J45.20 Mild intermittent asthma, uncomplicated
J45.21 Mild intermittent asthma with (acute) exacerbation
J45.22 Mild intermittent asthma with status asthmaticus
J45.3 Mild persistent asthma
J45.30 Mild intermittent asthma, uncomplicated
J45.31 Mild intermittent asthma with (acute) exacerbation
J45.32 Mild intermittent asthma with status asthmaticus
J45.4 Moderate persistent asthma
J45.40 Moderate persistent asthma, uncomplicated
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
J45.51 Severe persistent asthma with (acute) exacerbation
J45.52 Severe persistent asthma with status asthmaticus

Identify the Infection

Acute COPD with pneumonia is another problem area for many coders. For acute exacerbation of COPD with pneumonia, additional codes are required to identify the infection and the organization. Two codes will be assigned from category J44 along with a code from category J18 to designate the organism. The codes in category J44 distinguish between uncomplicated cases (J44.9) and those in acute exacerbation (J44.1).

COPD should be coded as the principal diagnosis with pneumonia sequenced as a secondary diagnosis. As an example, the following codes would be used for a patient with an acute exacerbation of COPD and streptococcus pneumonia.
J44.0 Chronic obstructive pulmonary disease with acute lower respiratory infection
J44.1 Chronic obstructive pulmonary disease with (acute) exacerbation
J13 Pneumonia due to streptococcus pneumonia
In another scenario, the patient comes in with a documented diagnosis of COPD with acute exacerbation; lobar pneumonia and acute on chronic hypoxic respiratory failure. The provider documents emphysema/COPD exacerbation. Best practices for the coder include the following:
• Refer to the alphabetic index: disease; lung; obstructive; with; acute; lower respiratory infection leads to J44.0
• Refer to the alphabetic index: disease; lung; obstructive; with; acute; exacerbation J44.1
• Refer to the alphabetic index: pneumonia; lobar J18.1
• Refer to the alphabetic index: failure; respiratory; acute and chronic; with; hypoxia J96.21
• Verify J44.0 in the tabular list, which states: “Use additional code to identify the infection.”

In this scenario the pneumonia would be the infection and should be coded as follows:

J44.0 Chronic obstructive pulmonary disease with acute lower respiratory infection
J44.1 Chronic obstructive pulmonary disease with (acute) exacerbation
J18.1 Lobar, pneumonia, unspecified organism
J96.21 Acute and chronic respiratory failure with hypoxia

Common Disease. Complicated Coding.

Even though COPD is a common disease in the U.S., its correct coding is important for proper tracking, treatment and management of this fragile patient population. When the diagnosis is stated only as COPD, the coder should review the medical record to determine whether a more definitive diagnosis is documented. If specification isn’t provided, a query to the provider is warranted.

Coders play an important role by ensuring ICD-10’s granularity for COPD, asthma and pneumonia are understood and properly documented.

Nena Scott, MSEd, RHIA, CCS, CCS-P, CCDS
AHIMA ICD-10-CM/PCS Trainer Certificate Holder
Director of Coding Quality and Professional Development
nena.scott@TrustHCS.com