Pulmonology Coding Alert

Find out whether you’re an expert COPD coder.

Your pulmonology practice is likely to see patients with chronic obstructive pulmonary disease (COPD) nearly every day, but that doesn’t mean you should use the same diagnosis code for every claim.

The subtleties and nuances between patients’ specific situations mean you’ll have to scrutinize every line of each medical chart before you can choose the most applicable diagnosis code.

Take a look at these four questions and determine whether you can select the right ICD-10 code before reading our solutions.

Question 1: Can You Code COPD With Bronchitis?

Scenario 1: 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 pulmonologist determines that the COPD patient is suffering from acute bronchitis stemming from rhinovirus. She prescribes antibiotics and steroids, and asks the patient to return if the symptoms worsen.

Coding solution 1: Although the codes for this scenario may not be tricky, the sequencing may be. You probably know to check your ICD-10 code book for “COPD with acute lower respiratory infection,” but the note under this code used to say “Use additional code to identify the infection,” and changed not long ago to “Code also to identify the infection” instead.

The “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 code book advises. On the other hand, the “use additional code” instruction “indicates that a secondary code should be added,” the code book says. In other words, the “use additional code” notation tells you to 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 pulmonologist.

Question 2: How Should You Code COPD Without Knowing the Cause?

Scenario 2: Your provider sees a patient who presents with cough, wheezing, and difficulty coughing up phlegm, and writes “COPD” on the chart with no other information.

Coding solution 2: In this case, your only solution is likely going to be J44.9 (Chronic obstructive pulmonary disease, unspecified).

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

If this happens more frequently than just on the occasional chart, then you should have a conversation with the pulmonologist and let them know that you’re unable to code to the highest degree of specificity without more information. Let them know that this could lead to denials, which can eventually result in lost income and slower reimbursement.

Question 3: Should You Report Additional Codes?

Scenario 3: A patient presents with COPD and the insurer denies the claim, noting that you should use a secondary code indicating the cause. What should you do?

Codling solution 3: You’ll have to go back to the progress notes to investigate whether the cause is indicated in the record. You’ll find that some payers want to see what the cause is, while others may not.

Most cases of COPD are caused by inhaling pollutants, such as cigarette or pipe smoke, chemicals, or environmental pollution. 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.

Question 4: How Do You Report COPD With Airway Obstruction?

Scenario 4: A patient who has had COPD for nine years presents with difficulty breathing. Upon examination, the pulmonologist 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 4: 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 (Chronic obstructive pulmonary disease with (acute) exacerbation).

The heading for J44 in the ICD-10 code book 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.