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

According to the Centers for Disease Control and Prevention, approximately 15.7 million Americans have been diagnosed with chronic obstructive pulmonary disease. The prevalence of COPD, coupled with the increased specificity required by ICD-10-CM, makes documenting the disease and any respiratory conditions currently associated with it imperative to ensure the appropriate diagnosis code is applied.

The two common forms of COPD are emphysema and chronic bronchitis. However, many patients diagnosed with COPD have both emphysema and chronic bronchitis.

Important tips to remember

• Always document and code to the highest level of specificity and report diagnosis codes at their highest number of characters available. For example, if the provider documents “acute bronchitis” or “chronic bronchitis” (both unspecified), then report ICD-10-CM codes J20.9 and J42, respectively. However, if the provider doesn’t indicate whether the bronchitis is acute or chronic, the appropriate ICD-10-CM code would be J40 (bronchitis not specified as acute or chronic). It’s important to indicate, through coding, whether 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 the specific details of the 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 information in the medical record is insufficient to assign a more specific code.
• 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 bronchitis) is assigned when the medical record supports acute bronchitis and COPD. (An additional code is used to identify the infection.)

It’s important to review the ICD-10-CM Chapter Specific Coding Guidelines (Chapter 10: Diseases of Respiratory System J00-J99) and 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 the ICD-10-CM Official Guidelines for Coding and Reporting.

ICD-10-CM diagnosis codes and ICD-10-CM Official Guidelines for Coding and Reporting are subject to change. It’s the responsibility of the provider to ensure that current ICD-10-CM diagnosis codes and the current ICD-10-CM Official Coding Guidelines for Coding and Reporting are reviewed prior to the submission of claims.

Keep in mind that 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 all applicable state and federal laws and regulations.