Otolaryngology Coding Alert

Choose the appropriate diagnosis after reading the case.

Although most otolaryngology practices see chronic obstructive pulmonary disease (COPD) patients somewhat frequently, that doesn't mean each diagnosis code is the same. In fact, for every three COPD patients you see, you may report three different ICD-10 code combinations, depending on the subtleties among the patients' conditions.

Check out the following three COPD scenarios and determine how you would code these cases.

COPD with Bronchitis

Scenario: A patient who has had COPD for six years presents complaining of shortness of breath, increased sputum, difficulty sleeping, and a runny nose. He says his granddaughter, who lives with him, recently suffered from rhinovirus. On examination, the physician determines that the COPD patient is suffering from acute bronchitis stemming from rhinovirus. She prescribes antibiotics and steroids, asking the patient to return if the symptoms worsen.

Coding solution: Although the codes for this scenario may not be tricky, the sequencing may be. As of October 1, 2017, you've had a new way to report COPD with acute lower respiratory infection. Although the code has remained the same, the note under it changed from "Use additional code to identify the infection" to "Code also to identify the infection" instead.

The new instructions "code also" note instructs that two codes may be required to fully describe a condition, but this note does not provide sequencing direction, the ICD-10 manualadvises. On the other hand, the old instructions, "use additional code" instruction "indicates that a secondary code should be added," the manual says. In other words, the "use additional code" notation tells use to use a secondary code after the main code, which means that this note does provide sequencing direction. Because of this change, you're able to determine which code should be listed first.

Therefore, in this situation, you'll report J20.6 (Acute bronchitis due to rhinovirus) followed by J44.0 (Chronic obstructive pulmonary disease with acute lower respiratory infection). The reason you'll report J20.6 first is because the bronchitis is the primary reason the patient presented to the otolaryngologist.

COPD with Acute Exacerbation

Scenario: A patient who has had COPD for eight months presents with difficulty breathing. Following a series of tests and an examination, the physician diagnoses the COPD patient with an acute exacerbation of her moderate persistent asthma.

Coding solution:  To report this condition, you may be tempted to choose J44.1 (Chronic obstructive pulmonary disease with [acute] exacerbation) and submit the claim, but you're not all the way there. Instead, you'll need to report two codes for this patient. First, list J45.40 (Moderate persistent asthma, uncomplicated) and then follow with J44.1.

Here's why: The ICD-10 manual lists a note under the heading to J44 (Other chronic obstructive pulmonary disease) that says, "Code also type of asthma, if applicable." Since you do know the type of asthma, that's why J45.40 is essential to report in addition to J44.1. As with the first example above, you are not required to bill either code as the primary when ICD-10 includes a "code also" note, leaving the physician to determine which should be the primary diagnosis. In most cases, since the patient is presenting to address the asthma, the provider will typically list that code first.

COPD with Airway Obstruction

Scenario: A patient who has had COPD for nine years presents with difficulty breathing. Upon examination, the physician finds a collection of mucus in the patient's throat. She trains the patient on how to use an Acapella device to expel the mucus so it doesn't get caught in his throat anymore. The patient is able to bring up the phlegm and his breathing becomes clearer.

Coding solution: Although this scenario sounds like it would require multiple codes, in this situation, just one code should do the trick: you'll report J44.1. The heading for J44 in the ICD-10 manual states that the code includes "chronic bronchitis with airway obstruction," which this patient has. The reason you'll bill a code that refers to an acute exacerbation is because the airway obstruction is an exacerbation of the COPD condition.