Coding corner: Medical record documentation for COPD and associated respiratory conditions

With the increased specificity required by ICD-10-CM, accurate and detailed medical record documentation is more important than ever. Chronic obstructive pulmonary disease and associated respiratory conditions need to be properly documented in the medical record to support the correct ICD-10-CM diagnosis code.

What is COPD?
Chronic obstructive pulmonary disease is a common and progressive disease that causes airflow from the lungs to be obstructed. Common symptoms include a productive cough, wheezing, shortness of breath and chest tightness. The two main forms of COPD are emphysema and chronic bronchitis. However, many patients with COPD have both emphysema and chronic bronchitis.

What causes COPD?
Smoking tobacco and exposure to tobacco smoke are the leading causes of COPD. According to the Centers for Disease Control and Prevention, smoking also accounts for as many as eight out of 10 COPD-related deaths. However, as many as one out of four people in the U.S. who have COPD never smoked cigarettes. Other causes include long-term exposure to lung irritants such as air pollution, chemical fumes and dust.

Tips to remember

• When coding for COPD, bronchitis (acute, chronic), asthmatic bronchitis (acute, chronic), emphysema and other associated respiratory conditions indicate through coding whether or not the condition is acute, chronic or in acute exacerbation.
• Since COPD-related conditions can be coded in a variety of ways, the final code selection must take into account all the specific details of a patient’s condition, as documented by the health care provider.
• ICD-10-CM code J44.9 (chronic obstructive pulmonary disease, unspecified) should only be used if the type of COPD being treated is not specified in the medical record.
• Always document and code to the highest specificity. For example, if the provider documents “acute bronchitis” or “chronic bronchitis” (both unspecified), then report ICD-10-CM codes J20.9 and J42.0, respectively. However if the provider does not indicate whether the bronchitis is acute or chronic, then the appropriate ICD-10-CM code would be J40 (Bronchitis not specified as acute or chronic).
• When COPD with an acute exacerbation is documented without acute bronchitis, then report ICD-10-CM code J44.1 (chronic obstructive pulmonary disease with acute exacerbation).
• Code J44.0 (chronic obstructive pulmonary disease with acute lower respiratory infection)when the medical record supports acute bronchitis and COPD. Use an additional code to identify the infection.

It’s important to review the ICD-10-CM Coding Guidelines (Chapter 10: Diseases of Respiratory System J00-J99), as well as any instructional notes under the various COPD subcategories and codes in the tabular list of the ICD-10-CM manual to select the correct code. In addition to the codes listed above, you may need to use additional codes to identify current or previous tobacco usage and dependence or other environmental exposure.

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

If you have questions or need more information, 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.