Primary Care Coding Alert

Remember that J44.9 doesn’t always paint the whole picture.

What do you do when your provider documents chronic obstructive pulmonary disease (COPD) in the patient’s record? Do you automatically document J44.9 (Chronic obstructive pulmonary disease, unspecified) and move on? Or do you dig further into the record to determine additional codes?

We posed this question to two expert coders and gathered their answers together to provide these five ways to help you code COPD and its associated respiratory disorders with the greatest specificity possible.

First, Know What COPD Is

To understand how to code the condition correctly, you first need to make sure you know exactly what it is. COPD is “is an umbrella term used to describe progressive lung diseases including emphysema, chronic bronchitis, and refractory (non-reversible) asthma,” according to the COPD Foundation (Source: www.copdfoundation.org/What-is-COPD/Understanding-COPD/What-is-COPD.aspx).

“This makes it difficult for a coder to know whether to code COPD or the other progressive lung diseases separately or as one code,” says Sherika Charles, CDIP, CCS, CPC, CPMA, compliance analyst with UT Southwestern Medical Center in Dallas, Texas.

“Differentiating between emphysema and chronic bronchitis would require lung function studies, blood gases, and X-rays,” adds Melanie Witt, RN, CPC, MA, an independent coding expert based in Guadalupita, New Mexico. However, “if there is a long history of cigarette smoking, which is the primary cause of COPD in the U.S., the physician is likely to suspect COPD at the first visit after listening to the lungs and taking a complete history,” Witt continues.

Second, Report Signs and Symptoms When There’s No Definitive Dx

“Initially, the patient may only present with a cough or shortness of breath,” Witt reminds coders. In this case, you should record symptoms as they appear in the medical record, which might include R06.02 (Shortness of breath), R06.2 (Wheezing), and/or R05 (Cough).

But if COPD is the definitive diagnosis and “stipulated by the provider in the medical record, coding for this situation would require a code from the J44 [Other chronic obstructive pulmonary disease] code category,” says Witt. That means starting your search with J44.9, though that may not be the only code you might use.

Third, Understand When to Use J44.9 Alone

“This code is reserved for the case where the provider has indicated a diagnosis of COPD but has not listed the cause, such as chronic bronchitis or emphysema,” says Witt. In other words, you should reserve the use of J44.9 for circumstances when your provider does not document associated manifestations, conditions, or exacerbations.

Fourth, Pay Attention to Related Conditions

COPD-related asthma: “If  your provider documents both COPD and COPD with acute asthma exacerbation, for example, then you should code J44.9 for the COPD along with J45.901 [Unspecified asthma with (acute) exacerbation] for the acute exacerbation of the asthma,” says Charles.

COPD with pneumonia: If both COPD and pneumonia are present, assign J44.9 with J18.9 (Pneumonia, unspecified organism) unless your provider documents another related cause. “Depending on the reason for the visit, either diagnosis may be sequenced first,” Charles reminds coders.

COPD with acute bronchitis: Here, you’ll code J44.0 (Chronic obstructive pulmonary disease with acute lower respiratory infection) first. Then, following the “Code Also” note that accompanies the code, which states “Code also to identify the infection,” you’ll chose a code from the J20.- (Acute bronchitis) category, using J20.9 (Acute bronchitis, unspecified) if your provider does not specify the infectious agent.

COPD with emphysema: “If your provider documents COPD, or COPD with exacerbation and emphysema, only the emphysema is reported,” says Charles, leading you to the J43 (Emphysema) codes if your provider documents these particular conditions. This is because there’s an Excludes1 note under J44 that references emphysema without chronic bronchitis (J43.-), which means the two conditions are mutually exclusive from an ICD-10 perspective.

“However, if COPD, emphysema, and chronic bronchitis are all documented, then only assign J44.9 for the COPD,” Charles continues, since a corresponding Excludes1 note under J43 refers ICD-10 users to J44 for emphysema with chronic (obstructive) bronchitis.

Fifth, Don’t Forget to Include Additional Codes

Finally, as Witt has already observed and the COPD Foundation emphasizes, genetics aside, “most cases of COPD are caused by inhaling pollutants.” These include “tobacco smoking (cigarettes, pipes, cigars, etc.) … second-hand smoke … [and] fumes, chemicals and dust found in many work environments” (Source: www.copdfoundation.org/What-is-COPD/Understanding-COPD/What-Causes-COPD.aspx).

So, where applicable, you will code:

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

You should also remember to code Z99.81 (Dependence on supplemental oxygen) if the patient is on long-term oxygen therapy for the condition.