Home Health ICD-9/ICD-10 Alert

Watch for changes in asthma classification.

Coding correctly for chronic obstructive pulmonary disease (COPD), obstructive bronchitis, and emphysema in ICD-9 requires you to have a thorough understanding of the details in your patient’s medical record. Don’t expect that to change as you make the transition to ICD-10. Take a look at how coding these conditions will change in the new code set.

Emphysema

Emphysema and chronic obstructive bronchitis are two types of chronic obstructive pulmonary disease (COPD) that often coexist. In ICD-9, when your patient is diagnosed with emphysema with chronic bronchitis, you code for it with 491.20 (Obstructive chronic bronchitis without exacerbation).

But when ICD-9 is replaced with ICD-10 on Oct. 1, you will switch from 491.20 to J44.9 (Chronic obstructive pulmonary disease, unspecified) for this patient. Take note: J44.9 is an unspecified code. If you’re able to gather more details about your patient’s condition, you’ll have an opportunity to choose a more specific code.

For patients with an emphysema diagnosis but no mention of obstructive bronchitis, you’ll report 492.8 (Other emphysema) in ICD-9. In ICD-10, look to category J43.- (Emphysema). For example, you’ll code for emphysema with chronic bronchitis that is exacerbated with J44.1 (Chronic obstructive pulmonary disease with [acute] exacerbation).

Coding COPD

A common complication with COPD is acute bronchitis. When your patient has COPD with an acute exacerbation and acute bronchitis, you should report 491.22 (Obstructive chronic bronchitis; with acute bronchitis) in ICD-9. You should not additionally report 466.0 (Acute bronchitis) for the obstructive chronic bronchitis since 491.22’s code descriptor specifies acute bronchitis.

In ICD-10 for this patient, you’ll have more codes to report. You would sequence J44.0 (Chronic obstructive pulmonary disease with acute lower respiratory infection) first, says Ann Zeisset, RHIT, CCS, CCS-P, AHIMA-Approved ICD-10-CM/PCS Trainer with Ann Zeisset Consulting in Trenton, Ill. You’ll see an instructional note in the Tabular List to add an additional code to identify the infection. In this case, that code comes from the J20.- (Acute bronchitis) category, and if the type of acute bronchitis is not further specified, the code is J20.9 (Acute bronchitis, unspecified). Finally, you’ll list J44.1.

Why so many codes? You’ll list J44.0 first to indicate the patient’s acute lower respiratory infection with COPD, Zeisset says. Next, you’ll report the acute bronchitis with a code from the J20.- category because of the “Use additional code to identify the infection” note at J44.0. This sequencing note means you can’t list the acute bronchitis first.

At category J20.-, you’ll see an Excludes 2 note that excludes acute bronchitis with chronic obstructive pulmonary disease (J44.0), Zeisset says. An Excludes 2 note means the condition is “Not included here.” So the condition excluded is not part of the condition represented by the code, but a patient may have both conditions at the same time and it’s OK to code for both. Since this patient has both conditions, it’s appropriate to add this code.

Finally, you want to list the acute exacerbation with J44.1. Even though there is an excludes note for J44.0 at this code, it is another Excludes 2, Zeisset points out. Since both conditions are present, you should code for them both.

Listing these codes covers the fact that the patient has COPD with an acute lower respiratory infection, specifies the type of infection, and indicates that the COPD is in exacerbation, says Therese Jorwic, MPH, RHIA, CCS, CCS-P, FAHIMA, assistant professor in Health Information Management at the University of Illinois at Chicago.

Note: When coding for COPD and many other respiratory conditions in ICD-10, you will need to additionally code any use of tobacco and exposure to environmental tobacco in ICD-10, says Zeisset. These codes include:

• Z77.22 (Contact with and [suspected] exposure to environmental tobacco smoke [acute] [chronic]);
  
• Z87.891 (Personal history of nicotine dependence);
  
• F17.- (Nicotine dependence);
  
• Z72.0 (Tobacco use); and
• Z57.31 (Occupational exposure to environmental tobacco smoke).
  

COPD and Asthma

When your patient has both COPD and asthma, you can code for both with a single code in ICD-9. For example, suppose your patient has COPD and an acute exacerbation of her asthma. You would report 493.22 (Chronic obstructive asthma with [acute] exacerbation) in ICD-9 for this patient.

But in ICD-10, you’ll need to report two codes for this patient. First, list J44.1 and then follow with a J45.- (Asthma) code to describe the type of asthma your patient has, as directed by the instructional note found at the J44.- category to code also the type of asthma if applicable.

Old: The classification for asthma in ICD-9 is intrinsic versus extrinsic, points out Zeisset. You’ll find codes in category 493.x (Asthma) for chronic obstructive asthma and other forms of asthma.

New: But the classification for asthma in ICD-10 is reflective of current terminology used in the field; intermittent versus persistent. Under the persistent category, you’ll find three levels: mild, moderate and severe persistent, Zeisset says.

The classification for asthma in ICD-10 is criteria based and uses the age and components of severity (impairment and risk), Zeisset says.

Impairment includes frequency of symptoms, number of nighttime awakenings, short-acting beta2-agonist use for symptom control, and interference of symptoms with normal activity, Zeisset explains.