Coding corner update: Improve medical record documentation for airway-related conditions

Beginning Oct. 1, 2015, the transition to ICD-10-CM will affect every area of health care. Many codes contain much greater specificity. This article includes updated codes to align with the transition to ICD-10-CM.

The overlap in terminology used to define airway-related conditions, such as chronic obstructive pulmonary disease, asthma, emphysema and chronic bronchitis, can often be confusing. The appropriate terminology for these conditions can best be determined through careful use of the ICD-10-CM Alphabetic Index.

Two particularly challenging conditions for coders are COPD and asthma. Although both share airway obstruction as a common feature, they’re at different ends of the clinical spectrum. However, the two conditions may overlap in many patients later in life.

Asthma often develops during childhood and can cause temporary airway obstruction. It’s often caused by allergies, too. In contrast, COPD usually develops later in life, is often related to smoking, and causes permanent airway obstruction. The two main forms of COPD are emphysema and chronic bronchitis. Asthma and COPD can often overlap, especially in elderly patients who might be affected by both diseases.

In ICD-10-CM, chronic obstructive asthma and asthma with COPD are reported with codes from the J44 category, other chronic obstructive pulmonary disease. Coding notes for this category state to code also the type of asthma, if applicable (J45.-). Use an additional code to identify exposure to tobacco smoke and tobacco use or dependence, if applicable.

Careful attention should be paid to documentation for a patient with a form of COPD and asthma. Here’s an example of how to assign diagnosis codes for a patient who’s affected by both conditions:

Assessment

• Acute exacerbation of COPD
• Acute bronchitis
• Acute exacerbation of asthma

Report diagnosis code J44.0, chronic obstructive pulmonary disease with acute lower respiratory infection for the COPD with acute lower respiratory infection (use additional code for the infection, bronchitis). Assign code J44.1, Chronic obstructive pulmonary disease with (acute) exacerbation, for the acute exacerbation of COPD; and code J45.901, unspecified asthma with (acute) exacerbation, for the acute exacerbation of asthma.

There’s an exclusion note under code J44.1 (COPD with acute exacerbation) that means multiple codes are required to code COPD with both an acute exacerbation as well as an acute respiratory infection.

The asthma category of codes has changed significantly in ICD-10-CM to reflect the current clinical classification of asthma. The following terms have been added to describe asthma: mild intermittent, mild persistent, moderate persistent and severe persistent. In addition, the ICD-10-CM codes also have the ability to identify with or without exacerbation and status asthmaticus. The classifications are determined by the frequency of the symptoms, exacerbation and status asthmaticus. Here are examples of the codes:

According to the ICD-10-CM guidelines, acute exacerbation is a worsening or a decompensation of a chronic condition. An acute exacerbation is not equivalent to an infection superimposed on a chronic condition, though an exacerbation may be triggered by an infection.Status asthmaticus is defined as a patient’s failure to respond to therapy administered during an asthmatic episode and is a life-threatening complication that requires emergency care.

ICD-10-CM coding for all conditions should follow coding conventions, chapter specific guidelines and general coding guidelines.

If you have any questions, contact your provider consultant.

None of the information included in this article is intended to be legal advice and, as such, it remains the provider’s responsibility to ensure that all coding and documentation are done in accordance with applicable state and federal laws and regulations.