March 26, 2017

COPD and Pneumonia: Code First or Code Also?

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One subject brought up several weeks ago on an edition of Talk Ten Tuesdays was the sequencing of J44.0, chronic obstructive pulmonary disease (COPD), with acute lower respiratory infection and pneumonia. Guest Stacey Elliot referred to the Coding Clinic from the third quarter of 2016, which says: “based on the instructional note, the COPD must be sequenced first.” She wanted to know if I thought ICD-10-CM needs to be updated or whether the Coding Clinic advice should be revised. My answer was actually yes to both.

First, just having COPD with an acute lower respiratory tract infection is not grounds for admission. In my experience, if a patient with COPD is not experiencing an exacerbation but is thought to require admission for treatment of pneumonia, then the condition that occasioned the admission is clearly the pneumonia, and that should be the principal diagnosis.

Secondly, the coding convention is that the underlying condition is sequenced first, if applicable, followed by the manifestation. This instruction makes no clinical sense. A manifestation is a condition expressed as a result of something else. Hemiplegia is a manifestation of a stroke, for example; metabolic encephalopathy is a manifestation of severe hyponatremia. Pneumonia is not a manifestation of COPD. It is a manifestation of a lung infection from some pathogenic organism. If you think about it, J44.0 is a manifestation of the acute lower respiratory tract infection; if bronchitis or pneumonia wasn’t present, the code would be J44.9, COPD, unspecified, instead.

So how about J44.1, COPD with acute exacerbation? As a public service announcement, let me remind you that the same Coding Clinic indicates that it is perfectly acceptable to assign both J44.0 and J44.1, when appropriate. But not every exacerbation of COPD and not every pneumonia patient needs to be admitted. In my opinion, a clinician should take into consideration the severity of the exacerbation and the extent and consequences of the pneumonia in deciding to admit. The COPD exacerbation requires respiratory treatment, ancillary medication, and continuous pulse oximetry; the pneumonia may require antibiotics, oxygen, and repeated CXRs. Both scenarios demand significant resources, and if there were no guidance as to sequencing, this would be one of those situations in which the coder has discretion to choose one or the other as principal.

Finally, the rule for the etiology/manifestation convention reads that “wherever such a combination exists, there is a ‘use additional code’ note at the etiology code, and a ‘code first’ note at the manifestation code to indicate the proper sequencing order.” J44.0 has a “use additional code to identify the infection” note, but the pneumonia diagnoses, such as in subcategories of J13-J18, have no such “code first” instruction for J44.0.

As a result of this exercise, I contacted the Centers for Disease Control and Prevention (CDC) and American Health Association (AHA), recommending to change the “use additional code” to “code also” and leave the sequencing to the discretion of the coder. Imagine my embarrassment when I was informed by my friend, Nelly Leon-Chisen, that on p. 102 of proposed addenda to the Tabular List of Diseases, the CDC’s plan was exactly that! Goes to show that you have to read every page from the ICD-10-CM Coordination and Maintenance Meeting minutes; ICD-10 is dynamic, and our feedback matters. So this problem is to be solved imminently.

Thanks for the opportunity to discuss this further. Keep your questions coming by emailing them to .
Erica E. Remer, MD, FACEP, CCDS

Erica Remer, MD, FACEP, CCDS has a unique perspective as a practicing emergency physician for 25 years, with extensive coding, clinical documentation improvement (CDI), and ICD-10 expertise. As a physician advisor for University Hospitals Health System in Cleveland, Ohio for four years, she has trained 2,700 providers in ICD-10, closed hundreds of queries, fought numerous DRG clinical determination and medical necessity denials, and educated CDI specialists and healthcare providers with engaging, case-based presentations. She transitioned to independent consulting in July 2016. Dr. Remer is a member of the ICD10monitor editorial board and the co-host of Talk Ten Tuesdays. She is also on the board of directors of the American College of Physician Advisors.

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