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May 11, 2009

Coding for Chronic Obstructive Pulmonary Disease
For The Record
Vol. No. P.

Chronic obstructive pulmonary disease (COPD) refers to chronic bronchitis, emphysema, and alpha-1 antitrypsin deficiency, a genetic form of emphysema. COPD is characterized by the obstruction of airflow and interference with normal breathing. Chronic bronchitis and emphysema frequently coexist.

Smoking is the primary risk factor for COPD. Other risk factors include secondhand smoke, a history of childhood respiratory infections, heredity, and air pollution. Occupational exposure to certain industrial pollutants also may increase the odds for developing COPD.

Chronic bronchitis is the inflammation and eventual scarring of the lining of the bronchial tubes. Emphysema begins with the irreversible destruction of air sacs (alveoli) in the lungs where oxygen from the air is exchanged for carbon dioxide in the blood. This damage results in permanent “holes” in the tissues of the lower lungs, and the patient experiences great difficulty exhaling.

COPD not elsewhere classified (ICD-9-CM code 496) is a nonspecific code that should only be used when the documentation in the medical record does not specify the type of COPD being treated.

COPD With Acute Bronchitis
A diagnosis of COPD and acute bronchitis is classified to code 491.22. It is not necessary to assign code 466.0 (acute bronchitis) with 491.22. Code 491.22 is also assigned if the physician documents acute bronchitis with COPD exacerbation. However, if acute bronchitis is not mentioned with the COPD exacerbation, then code 491.21 is assigned (AHA Coding Clinic for ICD-9-CM, 2008, fourth quarter, pages 241-244).

COPD With Asthma
Asthma with COPD is classified to code 493.2x. However, all coding directives in the Tabular List and index need to be reviewed to ensure appropriate code assignment. A fifth-digit subclassification is needed to identify the presence of status asthmaticus or exacerbation.

Exacerbation of COPD
Exacerbation is defined as a decompensation of a chronic condition. It is also defined as an increased severity of asthma symptoms, such as wheezing and shortness of breath. Although an infection can trigger it, an exacerbation is not the same as an infection superimposed on a chronic condition. Status asthmaticus is a continuous obstructive asthmatic state unrelieved after initial therapy measures. If a physician documents both exacerbation and status asthmaticus on the same record, only assign the fifth digit “1” to show the status asthmaticus. Sequence the status asthmaticus code first if documented with any type of COPD or with acute bronchitis (AHA Coding Clinic for ICD-9-CM, 2008, fourth quarter, pages 241-244).

COPD with exacerbation is classified to code 491.21, which also includes the following:

• acute exacerbation of COPD;

• exacerbation of COPD;

• decompensated COPD;

• decompensated COPD with exacerbation;

• COPD in exacerbation;

• severe COPD in exacerbation; and

• end-stage COPD in exacerbation.

The word “acute” need not be documented to assign code 491.21 for exacerbation of COPD (AHA Coding Clinic for ICD-9-CM, 2002, third quarter, page 18). “When the acute exacerbation of COPD is clearly identified, it is the condition that will be designated as the principal diagnosis” (AHA Coding Clinic for ICD-9-CM, 1988, third quarter, pages 5-6).

According to current coding advice, acute exacerbation of COPD, acute bronchitis, and acute exacerbation of asthma is classified to codes 491.22 and 493.22 (AHA Coding Clinic for ICD-9-CM, 2006, third quarter, page 20).

By far, the most important and effective treatment for COPD is smoking cessation. The benefits of quitting smoking apply regardless of age, amount smoked, or severity of COPD. Medications used to manage COPD include the following:

• Short-acting bronchodilators, both beta agonists (Albuterol, Xopenex, Isuprel, Alupent, Serevent) and anticholinergics (Atrovent), are the mainstays of COPD therapy. An inhaled combination product (Combivent), containing both anticholinergics and beta agonists, may also be used.

• Long-acting bronchodilators are indicated for moderate to severe COPD. Currently two beta agonists (formoterol and salmeterol) are available. A long-acting anticholinergic is under consideration for FDA approval.

• Inhaled corticosteroids (beclomethasone, Pulmicort, Aerobid, Flovent) are recommended for patients with moderate to severe COPD with frequent exacerbations.

• Oral or IV corticosteroids (dexamethasone, prednisone, methylprednisolone, hydrocortisone) are beneficial for treating severe exacerbations. Oral corticosteroids are generally not recommended for long-term use because of their potential side effects.

• Antibiotics are beneficial for treating chronic infections of the lower airways or suspected pneumonias accompanying acute COPD exacerbations. First-line antibiotic choices include amoxicillin, cefaclor, or Septra, while secondary treatment choices include azithromycin, clarithromycin, or fluoroquinolones (Levaquin).

• Theophylline in low doses may reduce the frequency of exacerbations in patients who tolerate it, but it has many side effects, such as anxiety, tremors, nausea, arrhythmias, and seizures.

• Mucolytics (Mucinex, Robitussin, Hytuss, Duratuss) make it easier to clear the mucus, which can be irritating and cause a cough.

• Newer drug therapies may include telithromycin (Ketek) to treat acute bacterial exacerbation of chronic bronchitis due to Strep pneumoniae, Haemophilus influenzae, or Moraxella catarrhalis; formoterol (Foradil) for long-term maintenance treatment of COPD and the acute prevention of exercise-induced bronchospasms, though it doesn’t eliminate the need for corticosteroid therapy and/or short-acting beta agonists where indicated; and tiotropium (Spiriva) for long-term maintenance treatment of bronchospasms associated with COPD, including chronic bronchitis and emphysema. Tiotropium is not intended for the treatment of acute bronchospasm.

In addition to medications, patients may require home oxygen, pulmonary rehab to improve overall quality of life and, in severe cases, surgery such as a lung transplant or lung volume reduction, during which the physician removes small wedges of damaged tissue.

Coding and sequencing for COPD are dependent on the physician documentation in the medical record and application of the Official Coding Guidelines for inpatient care. Also, use specific AHA Coding Clinic for ICD-9-CM and American Medical Association CPT Assistant references to ensure complete and accurate coding.

— This information was prepared by Audrey Howard, RHIA, of 3M Consulting Services. 3M Consulting Services is a business of 3M Health Information Systems, a supplier of coding and classification systems to more than 4,000 healthcare providers. The company and its representatives do not assume any responsibility for reimbursement decisions or claims denials made by providers or payers as the result of the misuse of this coding information. More information about 3M Health Information Systems is available at www.3mhis.com or by calling 800-367-2447.