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Emphysema is a form of. COPD, so you do not need to code J44.9. If patient also has asthma, code J45.X based on severity. J44.9. COPD, unspecified.
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*J44 includes all of the following: Note: Code also type of asthma, if applicable (J45.-J45.998) Bronchitis as acute or chronic or obstructive, when known Severity of COPD (mild, moderate, severe, end-stage) Results of pulmonary function tests Respiratory failure (acute or chronic) when it occurs as well as hypoxia or hypercapnia If Asthma with COPD (J44.x), include severity (mild, moderate, severe) type and status Dependence on ventilator and any tracheostomy Dependence on supplemental oxygen Tobacco use, counseling, treatment or intervention FLIP FOR BEYOND THE BASICS ICD 10 Code Description Consider Assigning When… J41.X Chronic Bronchitis Patient has simple and/or mucopurulent chronic bronchitis (Document if obstructive) J43.9 Emphysema, unspecified When patient has COPD and emphysema throughout. Emphysema is a form of COPD, so you do not need to code J44.9. If patient also has asthma, code J45.X based on severity. J44.9 COPD, unspecified Multiple diagnoses are under the J44.9 umbrella, including chronic obstructive asthma. Be sure to document severity as either mild, moderate or severe. J44.0 COPD w/ acute lower respiratory infection There is a worsening condition or decompensation. If appropriate, both can be documented. Also, be sure to include type of infection and infective agent. Caution: Do not use if infection is caused by influenza, ventilator or in cases of J44.1 COPD w/ (acute) aspiration pneumonia. In that instance use J44.9 and J95.851. exacerbation Use ALL applicable codes to accurately document a patient’s condition, more than 1 can be documented Remember to M.E.A.T. (Monitor, Evaluate, Assess and/or Treat) and document: Asthma with COPD Chronic asthmatic (obstructive) bronchitis Chronic bronchitis with airways obstruction Chronic obstructive asthma Chronic bronchitis with emphysema Chronic emphysematous bronchitis Chronic obstructive tracheobronchitis Chronic obstructive bronchitis
ICD10 CODING CONSIDERATIONS MEDICATION AND TREATMENT Can support diagnosis of COPD, so be sure to document any of the following: ICD10 Code Description Z99.11 Dependence on respirator [ventilator] status Z99.81 Dependence on supplemental oxygen Z79.51 Long term (current) use of inhaled steroids Z79.52 Long term (current) use of systemic steroids
COPD can occur with or without acute or chronic respiratory failure. Document respiratory failure for encounters. Also consider documentation of hypoxia or hypercapnia in respiratory failure: ICD10 Code Complication J96.01 Acute respiratory failure with hypoxia (oxygen deficient) J96.12 Chronic respiratory failure with hypercapnia (excess carbon dioxide) ICD10 Code Comorbidity J45.X Asthma (including persistence) E66.X Obesity and Overweight, also be sure to document BMI I27.23 Pulmonary HTN due to lung disease and hypoxia code also lung disease J85.1 Abscess of Lung or Pneumonia Example ICD 10 Coding Patient has COPD with acute exacerbation of moderate persistent asthma, O2 dependent, and history of 10 years tobacco dependence.
When coding for COPD it is important to remember to document diagnosis severity:
Or medical conditions that exist at the same time as diagnosis or later develop in conjunction with COPD Common comorbidities with COPD include: ICD10 Code Description F17.X Nicotine dependence Z72.0 Tobacco Use Z77.22 Contact with and (suspected) exposure to environmental tobacco smoke (acute/ chronic) Z87.891 History of nicotine dependence
It is important to obtain patient’s smoking status when they have any chronic lung disease Also, be sure to document tobacco counseling, treatment or intervention Diagnosis Severity Classifications Bronchitis Chronic or Acute COPD Mild, Moderate or Severe Asthma Mild Intermittent, Mild Persistent, Moderate Persistent, Severe Persistent AND Status