Chronic obstructive pulmonary disease

This PDF was generated from an article on http://drhoffman.com/ © 2017 Ronald L. Hoffman MD, PC. All Rights Reserved | 1 Emphysema is a form of chronic obstructive pulmonary disease (COPD) that involves permanent abnormal enlargement of gas exchange airways accompanied by destruction of lung alveoli (the little sacs where oxygen and carbon dioxide pass across a thin membrane into and out of the blood vessels). In emphysema, obstruction occurs as a result of loss of elasticity in lung tissues.


Types
There are two main types of COPD, and most people with COPD have a combination of both conditions:  Emphysema (slowly progressive destruction of the lung tissue, which loses its elasticity and ability to expand and contract)  Chronic bronchitis (long-term, chronic inflammation and cough with mucus, resulting in narrowing and blockage of the airways) Bronchiectasis is not a type of COPD COPD and bronchiectasis are two separate chronic lung conditions that can coexist. Although there are some similarities between the two, there also are some important differences and the conditions are treated differently.  COPD includes a range of chronic, progressive, obstructive lung diseases usually caused by smoking and other environmental factors.  Bronchiectasis is usually caused by inflammation and infection of the small airways (bronchi), which results in thickening and scarring of the airway walls. This airway damage prevents the natural clearing of mucus; thus, mucus accumulates and creates an environment in which bacteria can grow. This leads to a recurring cycle of inflammation and infection that can cause even more damage to the airways. Over time, the damaged airways lose their ability to effectively move air in and out, resulting in lack of adequate oxygen reaching vital organs. This can lead to serious health problems, such as respiratory failure and heart failure. In the subjective section of the office note, document the presence or absence of any current symptoms related to chronic obstructive pulmonary disease (e.g., shortness of breath, cough, fatigue, etc.).

Objective
The objective section should include all current associated physical exam findings (e.g., decreased breath sounds, wheezing, etc.) and related diagnostic test results, such as pulmonary function tests (PFT).

Assessment
American Hospital Association (AHA) Coding Clinic advises COPD is a chronic, systemic condition that almost always affects patient care, treatment or management. Therefore, it is appropriate to document the COPD diagnosis in the final assessment as a current, coexisting condition, even in the absence of specific treatment of the condition on an individual date of service.
Managed by a different provider  Even when the COPD condition is being followed and managed by a different provider, it is important to include the diagnosis in the final assessment.  For example: "Chronic emphysematous bronchitis followed and managed by pulmonologist, Dr. Jane Smith." Specificity:  Describe each final COPD-related diagnosis to the highest level of specificity. A diagnosis of "COPD" is broad and nonspecific-it does not identify the particular type of COPD or any associated conditions.  Include the current status (stable, worsening, improved, etc.)

Abbreviations:
A good rule of thumb for any medical record is to limit-or avoid altogether-the use of abbreviations. While COPD is a commonly accepted medical abbreviation for chronic obstructive pulmonary disease, best practice is as follows:  The initial notation of an abbreviation should be spelled out in full with the abbreviation in parentheses: "Chronic obstructive pulmonary disease (COPD)."  Subsequent mention of the condition can be made using the abbreviation.
Suspected versus confirmed:  Do not document a suspected COPD condition as if it is confirmed. Instead, document the signs and symptoms in the absence of a confirmed diagnosis.  Do not describe a confirmed COPD diagnosis with terms that imply uncertainty (such as "probable," "apparently," "likely" or "consistent with").
Treatment plan  Document a clear and concise treatment plan for COPD, linking related medications to the diagnosis.  Include orders for diagnostic testing.  Indicate in the office note to whom or where the referral or consultation requests are made.  Document when the patient will be seen again, even if only on an as-needed basis.
Electronic health record (EHR) issues Some electronic health records insert ICD-10-CM codes with descriptions into the medical record to represent the final diagnosis.
Example: "J43.8 Other emphysema" This can result in a vague diagnosis that is not complete. In this example, complete and accurate documentation requires the provider to clearly describe the particular "other" emphysema that codes to J43.8 (example: paraseptal emphysema).
Codes titled "other" or "other specified" are for use when the information in the medical record provides a specific diagnosis for which a specific code does not exist.  Alphabetic Index entries in the coding manual with NEC (not elsewhere classified) in the line designate "other" codes in the Tabular List.  These Alphabetic Index entries represent specific disease entities for which no specific code exists so the term is included within an "other" code.  The "other" ICD-10-CM code with description should not be used, by itself, as a final diagnosis without clear documentation of the particular "other" condition. Reference: ICD-10-CM Official Guidelines for Coding and Reporting, Section I.A.9.a -"Other" codes Chronic obstructive pulmonary disease ICD-10-CM Best documentation practices for physicians Another scenario that causes confusion is one in which the assessment section documents a final diagnosis PLUS an EHR-inserted diagnosis code with description that does not match or may even contradict the stated diagnosis. Example: Assessment: Panlobular emphysema J43.9 Emphysema, unspecified In this scenario, the final diagnosis in bold in the Assessment is "Panlobular emphysema", which codes to J43.1. The EHR-inserted diagnosis code with description is J43.9, Emphysema, unspecified. This leads to confusion regarding which diagnostic statement is correct and which code should be reported. Overall context of the record does not always provide clarity.
To avoid confusion and ensure accurate diagnosis code assignment, the provider's final diagnosis must either a) match the code with description; OR b) it must classify in ICD-10-CM to the EHR-inserted diagnosis code with description.
Note: ICD-10-CM is a statistical classification; it is not a substitute for a healthcare provider's final diagnostic statement. It is the healthcare provider's responsibility to provide legible, clear and concise documentation of each final diagnosis described to the highest level of specificity, which is then translated to a code for reporting purposes. It is not appropriate for healthcare providers to simply list a code number or select a code number from a list of codes in place of a written final diagnosis.
Chronic obstructive pulmonary disease ICD-10-CM Tips and resources for coders Coding basics COPD and its associated conditions classify to the following categories: J43 Emphysema J44 Other chronic obstructive pulmonary disease J45 Asthma Multiple instructional notes appear under each of these categories. To ensure accurate and specific diagnosis code assignment, the coder must note the exact diagnosis description in the medical record; then, in accordance with ICD-10-CM official coding conventions and guidelines:  Search the alphabetic index for that specific description.  Verify the code in the tabular list, following all instructional notes, as applicable.
COPD COPD classifies to category J44 with a fourth character required as follows to provide further specificity: J44.Ø COPD with (acute) lower respiratory infection J44.1 COPD with (acute) exacerbation J44.9 Chronic obstructive pulmonary disease, unspecified Multiple instructional notes appear under these categories.
COPD with coexisting asthma COPD with unspecified asthma is included in category J44 and codes to J44.9.
When the type of asthma is further specified, two codes are assigned: A code from category J44 for COPD; and a code from category J45 to report the type of asthma. Fourcharacter subcategories under J45 include the following: J45.2-Mild intermittent asthma J45.3-Mild persistent asthma J45.4-Moderate persistent asthma J45.5-Severe persistent asthma J45.9-Other and unspecified asthma Fifth and sixth characters are added to report whether asthma is uncomplicated, with exacerbation, or with status asthmaticus.
COPD with exacerbation of asthma codes to J44.9 and J45.9Ø1, Unspecified asthma with (acute) exacerbation. Although code J45.9Ø1 does not represent a type of asthma, it further specifies the asthma is in acute exacerbation.
When a medical record documents both acute exacerbation of asthma AND status asthmaticus, only the code for the more severe condition (status asthmaticus) should be assigned.
COPD with exacerbation and acute bronchitis Exacerbation of COPD is a periodic worsening, flare-up or decompensation of symptoms. An acute exacerbation is not equal to an infection superimposed on COPD (though COPD exacerbation may be triggered by an infection).
Code J44.1, COPD with exacerbation, has an Excludes2 note advising code J44.Ø (COPD with acute bronchitis) is not part of the condition represented by code J44.1. This indicates it is acceptable to assign both codes when the medical record shows both conditions are present. The record does not have to specifically state the exacerbation is acute to assign code J44.1, as "acute" is enclosed in parentheses as a nonessential modifier -a word that may be present or absent in the statement of a disease without affecting the code to which it is assigned. "Acute" is inherent to exacerbation.
COPD with acute bronchitis (an acute infection) is coded:  J44.Ø Chronic obstructive pulmonary disease with (acute) lower respiratory infection  J2Ø.9 Acute bronchitis, unspecified COPD with coexisting bronchiectasis Even though COPD and bronchiectasis are different and separate lung diseases, the ICD-10-CM classification indicates that when a record documents COPD coexisting with bronchiectasis, a code from only category J47 is assigned.
In the alphabetic index, bronchiectasis does not appear under Disease, pulmonary. However, the coder is advised to see also Disease, lung. This leads the coder to Disease > lung > obstructive (chronic) > with > bronchiectasis J47.9.  Category J47, bronchiectasis, has multiple instructional notes and fourth characters to provide greater specificity.  Category J44 Excludes1 COPD with bronchiectasis and directs the coder to category J47. Other reminders  Pneumonia is not an acute exacerbation of COPD. When these two conditions coexist, code them separately.  Hypoxia is not inherent in COPD. When COPD is documented with hypoxia, code RØ9.Ø2, Hypoxemia, may be assigned as an additional diagnosis.

Coding examples
Example 1 Final diagnosis COPD ICD-10-CM code J44.9 Chronic obstructive pulmonary disease, unspecified Comment A vague and nonspecific condition description leads to a vague and nonspecific ICD-10-CM code.
Example 2 Final diagnosis Emphysema ICD-10-CM code J43.9 Emphysema, unspecified Comment Emphysema is a more specific type of COPD.
Example 3 Final diagnosis COPD with emphysema ICD-10-CM code J43.9 Emphysema, unspecified Comment Emphysema is a more specific type of COPD. Following the coding path in the ICD-10-CM manual, "Disease > pulmonary > chronic obstructive" does not have a sub-term entry for "with emphysema." Therefore, the coder should follow the instruction to see also "Disease, lung." Disease > lung > obstructive (chronic) > with > emphysema > J43.9.

Example 4
Final diagnosis COPD with emphysema and chronic bronchitis ICD-10-CM code J44.9 Chronic obstructive pulmonary disease, unspecified Comment Code J43.9, Emphysema, unspecified, Excludes1 emphysema with chronic (obstructive) bronchitis and redirects the coder to category J44. Category J44, Other chronic obstructive pulmonary disease, includes chronic bronchitis with emphysema.