Pulmonology Coding Alert

Don’t miss these 2017 tweaks to your Excludes notes.

ICD-10-CM provides some clarity for what is covered under the COPD codes, minimizes ambiguity, and reduces the number of inclusive conditions, unlike the good old ICD-9-CM days, when COPD was a catch all for a laundry list of conditions. “Clarification and quantification of the patient’s condition can be captured better with ICD-10,” says Carol Pohlig, BSN, RN, CPC, ACS, senior coding and education specialist at the Hospital of the University of Pennsylvania.

Read This COPD Coding Refresher

ICD-10-CM offers three options, with specificity in mention of associated factors as well. 

Basics: Chronic obstructive pulmonary disease, or COPD is a progressive lung disease in which obstruction in the flow of air disturbs the normal breathing pattern; it includes pathologies such as emphysema or chronic bronchitis.

“My concerns with coding COPD are the doctor not coding to the highest specificity,” says Lisa Center, CPC, Physician Practice Manager, Via Christi Hospital Pittsburg, Inc. Pittsburg, KS. ”We have been getting denials asking for more information. Our providers usually code ‘unspecified’ so education has been key.”

As for the coding guidelines, ICD-10 codes are more specific and have lesser inclusivity. COPD allows for clear delineation of the disease as either an uncomplicated case, or in acute exacerbation. In other words, COPD is a condition for which clarity has improved in ICD-10-CM. “However, unless the patients’ problem lists have been updated with the appropriate codes (rather than just cross-walked from ICD-9 codes), the specificity may have been lost,” opines Pohlig. Code J44.- (Other chronic obstructive pulmonary disease) offers you the following code options:

• J44.0 (Chronic obstructive pulmonary disease with acute lower respiratory infection)
• J44.1 (Chronic obstructive pulmonary disease with [acute] exacerbation)
• J44.9 (Chronic obstructive pulmonary disease, unspecified).

Acute exacerbation: When the condition is documented as an acute exacerbation, it is considered to be worsening, or (is) a decompensation of a chronic condition. Acute exacerbation means worsening or decompesation, it does not mean infection and may be triggered by infection.

Tip: When coding for COPD, be sure to review the notes in the Tabular List under other chronic obstructive pulmonary diseases (J44), to see what conditions fall under this heading, and for code also notes. 

For example, when reporting J44.0, remember to use additional code to identify the infection. Furthermore, it is worthwhile note that J44.1 also covers decompensated COPD, but excludes COPD with acute bronchitis.

Moreover, J44.- requires you to code also the type of asthma, if applicable (J45.-)

You may need to use additional code, such as Z77.22 (Contact with and [suspected] exposure to environmental tobacco smoke [acute] [chronic]).

Take Note of These 2017 Changes

First of all, you should note that Z87.891 (History of tobacco use) has been revised to “Personal history of tobacco dependence” as per the 2017 update to the existing ICD 10 codes, and these changes will take effect from October 2016. 

Further, the Excludes1 note “lung diseases due to external agents (J60-J70)” has been deleted, and an Excludes2 note with the same descriptor replaces it. 

Remember the Excludes1 note: Bronchiectasis (J47.-), chronic bronchitis NOS (J42), chronic simple and mucopurulent bronchitis (J41.-), chronic tracheitis (J42), chronic tracheobronchitis (J42), emphysema without chronic bronchitis (J43.-), lung diseases due to external agents (J60-J70).

To sum up: You will need to be careful of using the exact codes meant for infection versus acute exacerbation, while keeping in mind the new Excludes2 note for the code.

“As with ICD-9, and given the fully realized implementation of ICD-10, practices must remember to review and incorporate ICD-10 annual updates (which have now resumed),” Pohlig says. “Be sure to update the patients’ problem list when they are seen, to reflect any changes or updates in their conditions.” 

Education therefore seems to be of paramount importance. “My biggest advice is educating providers,” Center says. “Proper coding starts with their documentation and the more information they put in their notes, the better.”