Tune in to this monthly online coding column, facilitated by AHIMA’s coding experts, to learn about challenging areas and documentation opportunities for ICD-10-CM/PCS.
By Elena Miller, MPH, RHIA, CCS
Recently, Coding Clinic provided clarification regarding code selection when both chronic obstructive pulmonary disease (COPD) and emphysema are documented in the record. The seemingly clear explanation sparked some conversations and questions. Some had never thought of COPD in terms of “type” of COPD. The Coding Clinic update prompted me to research the condition to gain a better understanding.
Dorland’s medical dictionary describes COPD as any disorder characterized by persistent or recurring obstruction of bronchial air flow. Chronic obstructive bronchitis and emphysema are two conditions that comprise COPD. Both are commonly caused by smoking, and many patients have features of both conditions and the two often occur together.
The symptoms and treatment of these conditions are very similar, but there is a difference in the coding of these two conditions. See the table below for a comparison of the symptoms and treatment of chronic bronchitis and emphysema.
The three following example coding scenarios will give the basis for further discussion.
Coding Scenario #1
The physician documents COPD with chronic bronchitis and emphysema in the record. Per Coding Clinic, Fourth Quarter ICD-10 2017 pg. 97, assign code J44.9, Chronic obstructive pulmonary disease, unspecified. Code J43.9, Emphysema, unspecified, has an excludes1 note excluding “emphysema with chronic (obstructive) bronchitis.” Category J44, Other chronic obstructive pulmonary disease, includes chronic bronchitis with emphysema.
Coding Scenario #2
The physician documents COPD with emphysema and there is no mention of chronic bronchitis in the record. Per Coding Clinic, Fourth Quarter ICD-10 2017 pg. 97, Assign code J43.9, Emphysema, unspecified. Remember that Category J44, Other chronic obstructive pulmonary disease, includes chronic bronchitis with emphysema. In this scenario, there was no mention of chronic bronchitis.
Coding Scenario #3
The physician documents exacerbation of COPD with emphysema, with no mention of chronic bronchitis. Per Coding Clinic, Fourth Quarter ICD-10 2017 pg. 97, Assign code J43.9, Emphysema, unspecified. Emphysema without mention of chronic bronchitis is classified to category J43, Emphysema. COPD is not synonymous with chronic bronchitis. So, “COPD exacerbation with emphysema” is assigned code J43.9 because “COPD” does not automatically mean the patient has chronic bronchitis. Emphysema is a type of COPD. Please note that if exacerbation of COPD is documented in the record of a patient with both emphysema and chronic bronchitis, then the correct code is J44.1, COPD with acute exacerbation.
One thing to note is that in all three of these example coding scenarios, emphysema is documented in the record. These coding clinics are specific to code assignment around emphysema, which is a type of COPD. Do not confuse the Coding Clinic update to mean that J43.9 is coded when only COPD is documented and chronic bronchitis is not mentioned. J43.9 only comes into play when COPD is documented WITH emphysema and there is no mention of chronic bronchitis.
According to the AHIMA Guidelines for Achieving a Compliant Query Practice, a query should be considered when the medical record documentation describes or is associated with clinical indicators without a definitive relationship to an underlying diagnosis. In the case of a patient who presents with emphysema and is noted to have a chronic cough or is experiencing a mucus-producing cough, a query may be warranted to determine if the patient also carries a diagnosis of chronic bronchitis. It’s definitely worth a conversation with coding leadership, clinical documentation improvement staff, and the pulmonary medical staff to ensure that these cases are properly identified to ensure accurate coding.
Elena Miller is the director of coding audit and education at a healthcare system.