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July 2016

Ask the Experts
For The Record
Vol. 28 No. 7 P. 10

Regarding ICD-10-CM code J44.0 (COPD with acute lower respiratory infection, use additional code to identify the infection): I understand that J44.0 would be used to identify infections from categories J20 to J22 with COPD. But what about pneumonia, J18.9?

According to coding conventions, the use of an additional code means the additional code would be a secondary code. So if you used J44.0 to identify a patient with acute pneumonia and chronic COPD, the COPD code would go first and the diagnosis-related group (DRG) would be a COPD DRG instead of the acute condition of pneumonia.

In the coding handbook, there are three examples, and they are conflicting in the use of this code with pneumonia.

• Case summary exercise 1, respiratory system
Discharge diagnoses: (1) Acute respiratory failure with hypoxia secondary to chronic obstructive bronchitis, (2) pneumonia, (3) encephalopathy.
J44.1 COPD with (acute) exacerbation
J18.9 Pneumonia, unspecified organism

• Case summary exercise 3, respiratory system
Discharge diagnoses: (1) Right lower lobe pneumonia due to Streptococcus pneumoniae, (2) acute exacerbation of chronic obstructive lung disease.
J13 Pneumonia due to Streptococcus pneumoniae
J44.1 COPD with (acute) exacerbation

• Case summary exercise 11, respiratory system
Discharge diagnoses: (1) Arteriosclerotic heart disease, (2) congestive heart failure, (3) pneumonia, (4) chronic obstructive lung disease.
J18.9 Pneumonia, unspecified organism
J44.0 COPD with acute lower respiratory infection
Comment for example: Code J44.0, COPD with acute lower respiratory infection, is assigned instead of J44.9 because of the presence of pneumonia.

It is confusing that J44.0 was not used in the other two examples with pneumonia.

Nancy Deemer, CCS
Lee Memorial Health System
Fort Myers, Florida

If a COPD patient comes in with pneumonia and not an exacerbation of COPD, code the pneumonia first.

If a patient with COPD gets an acute exacerbation from any respiratory illness (asthma, bronchitis, pneumonia, etc), sequence the appropriate exacerbation code first.

When advice comes out, you'll never be criticized for doing it this way based on existing guidance.

— The late Robert S. Gold, MD.


I have a question regarding the coding of repair of third-degree obstetric (OB) perineal laceration. We are having disagreement over whether to use one or two codes. Some of the advice we are getting tells us that two codes are necessary for repair of all third-degree OB lacerations: 0DQR0ZZ for repair of anal sphincter, open approach, and 0KQM0ZZ for repair of perineum muscle, open approach.

The documentation in my chart says that the anal sphincter was repaired but makes no mention of a repair of muscle. Can I just use the code for repair of anal sphincter, or do I need both codes for this procedure?

Rosey Andrzejczyk, RHIT
HealthEast Care Systems
St. Paul, Minnesota

With regard to an OB laceration, reviewing the extent of the lacerations per the AHA ICD-10 Coding Handbook, Chapter 24:

• First-degree tears (O70.0) involve damage to the fourchette and vaginal mucosa, and underlying muscles are exposed but not torn.

• Second-degree tears (O70.1) include the posterior vaginal walls and perineal muscles, but the anal sphincter is intact.

• Third-degree tears (O70.2) extend to the anal sphincter, but the rectal mucosa is intact.

• Fourth-degree tears (O70.3) involve the rectal and anal mucosa.

The lacerations get deeper and extend longer, consuming more area of the female genital area, as the degree progresses.

Per the Official Coding Guidelines, B3.1.b, "Procedural steps necessary to reach the operative site and close the operative site, including anastomosis of a tubular body part, are also not coded separately."

Per the Official Coding Guidelines, B3.2.a, multiple procedures are coded if "the same root operation is performed on different body parts as defined by distinct body part values of the body part character."

Per the Official Coding Guidelines, B3.5, "If the root operations Excision, Repair or Inspection are performed on overlapping layers of the musculoskeletal system, the body part specifying the deepest layer is coded."

Both the second-degree perineal laceration and a third-degree anal sphincter laceration involve muscle. Therefore, they are both the same layer of two different body parts identified by a body part value.

In conclusion, if only the anal sphincter is documented as being closed, then 0DQR0ZZ, repair of anal sphincter, open approach, would be captured, as it was the deepest layer of that particular body part that is documented. Without documentation of the second-degree perineal muscle laceration repair, I would not recommend capturing that "every time" in a blanket statement.

Further clarification is required from the American Hospital Association's (AHA) Coding Clinic to discern if the second-degree perineal could be captured in addition to the anal sphincter repair, with additional documentation present, as both reside at the same depth but are distinct body part values. I submitted it to Coding Clinic, reference number 50014054.

— Jill A. Lively, RHIT, CCS-P, is a senior coding consultant and an AHIMA-approved ICD-10-CM/PCS trainer at Peak Health Solutions.


I have an operative report that includes the following statement: A silk suture was tied to the fistula probe and brought through the tract. This suture was tied to two vessel loops, which were brought through the tract. Each of these were tied externally using 0 Vicryl silks and left in place as noncutting setons.

I had planned on using 46020; however, some feel that this would be used for a cutting seton only.

Greta Ryan, RHIA, CCS, CCS-P
Memorial Health System
Springfield, Illinois

A seton is a piece of surgical thread that is put into place to allow an anal fistula to remain open and to allow for drainage. This type of seton is placed loosely, in a noncutting fashion. Sometimes a seton is placed to create scar tissue or it can be tightened over time to cut through the fissure. This type of seton is gradually tightened (in-office procedure) and may take several weeks before it cuts all the way through.

The description of CPT 46020, Placement of seton, does not distinguish between a draining or cutting seton. Based on the provided statements, it would be appropriate to use CPT 46020. The entire operative report would need to be reviewed in order to provide a more comprehensive response regarding coding the procedure(s) performed.

— Barbara Hayes, RHIT, CPC, RCC, is director of outpatient compliance and education for Anthelio Healthcare Solutions.


What is the correct ICD-10 code for a patient admitted to the hospital who meets sepsis criteria and is found to be positive for influenza? The physician documented viral sepsis related to influenza.

Joan C., CCS
Garden City, New York

Ah, the ages-old "viral sepsis" conundrum. The hospital I used to work for actually submitted this for a Coding Clinic and received interim advice that never ended up getting published, which is too bad, because it made pretty good sense (and still does). In short, my answer is immediately below, with some [additional info] to follow:

Per the AHA's ICD-10-CM guidelines, if sepsis meets the criteria for a principal diagnosis and the underlying infection is present and documented: "A code(s) for the underlying systemic infection should be assigned first and the code for the localized infection should be assigned as a secondary diagnosis."

So, in this case, A41.89, Other specified sepsis, would work for the principal diagnosis followed by the appropriate viral infection code. So, for example, viral sepsis due to confirmed influenza B pneumonia could be A41.89 + J10.00.

I do not currently have any Coding Clinic or "excludes" notes that conflict with the above advice, but I expect there will eventually be some additional advice. A common error I see is coders going down the viral sepsis pathway when the identified organism is H. influenzae, which is a bacterium.

ICD-9 was a bit muddier because the Coding Clinic for nonbacterial sepsis was about candidiasis, and in ICD-9 there was a code for systemic candidiasis; inconveniently, there is no "systemic influenza" code for ICD-10, thus my above advice.

Let me know if that makes sense; I know this is a hotly debated issue with lots of competing opinions.

— Jonathan LaFleur, RN, CCS, is an auditor for HRS with over 16 years of health care experience, both at the bedside and in HIM.

I am a medical record DRG auditor. My management advises for a scenario of sepsis with influenza—no bacterial infection—code to the flu since the sepsis code A41.89 relates to bacterial infections. My example did not indicate any bacterial infection such as pneumonia. I agree that your example of A41.89 and J10.00 looks correct. Perhaps with the thousands of new ICD-10 codes coming in October, there will be better guidance in the index for a code that fits these tricky scenarios.

Joan C., CCS