Coding Tip: Chronic Obstructive Pulmonary Disease (COPD)

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Capturing and Coding Chronic Obstructive Pulmonary Disease (COPD)

Rationale

-- Chronic obstructive pulmonary disease (COPD) is a broad term that represents a group of chronic, progressive lung diseases that obstruct the airways in the lungs, making it difficult to breathe.

-- There are two main types of COPD, and most people with COPD have a combination of both conditions:

• Emphysema – a slowly progressive destruction of the lung tissue, which loses its elasticity and ability to expand and contract
• Chronic bronchitis – a long-term, chronic inflammation and cough with mucus, resulting in narrowing and blockage of the airways

-- COPD includes a range of chronic, progressive, obstructive lung diseases usually caused by smoking and other environmental factors.

-- 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.

-- 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.

-- The American Hospital Association (AHA) Coding Clinic advises that 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.

How to Code & Document

Subjective

• In the subjective section of the office note, document the presence or absence of any current symptoms related to chronic obstructive pulmonary disease (such as shortness of breath, cough, fatigue, etc.).

Objective

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

Assessment

• 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.)

Suspected vs. 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.

Coding COPD

COPD and its associated conditions classify to the following categories:

• J43 Emphysema
• J44 Other chronic obstructive pulmonary disease
• J45 Asthma

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
• 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. Four-character subcategories under J45 include the following:

• J45.2x Mild intermittent asthma
• J45.3x Mild persistent asthma
• J45.4x Moderate persistent asthma
• J45.5x Severe persistent asthma
• J45.9x Other and unspecified asthma

Fifth and sixth characters are added to report whether asthma is uncomplicated, with exacerbation or with status asthmaticus.

• J45.9x Other and unspecified asthma

·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

Emphysema classifies to category J43 and is a more specific type of COPD. A fourth character is required to specify the particular type of emphysema.

• J43.Ø Unilateral pulmonary emphysema (MacLeod’s syndrome)
• J43.1 Panlobular emphysema
• J43.2 Centrilobular emphysema
• J43.8 Other emphysema
• J43.9 Emphysema, unspecified

Please note:

• Emphysema documented with coexisting chronic bronchitis classifies to category J44.
• Emphysema without mention of chronic bronchitis classifies to category J43.