Coding Tip: COPD and Pneumonia Sequencing FY 2018
This Coding Tip was updated on 12/10/2018
Kim Carrier RHIT, CDIP, CCS, CCS-P
Director of Coding Quality Assurance
AHIMA Approved ICD-10-CM/PCS Trainer
The change to the instructional notes for ICD-10-CM code J44.0 is a hot topic in coding right now !
How does a coder sequence COPD and pneumonia?
As of October 1, 2017 the note under the code J44.0 COPD (chronic obstructive pulmonary disease, with acute lower respiratory infection) was changed from “Use additional code to identify infection” to “Code also to identify the infection”. A “code also” note does NOT give a sequencing directive as the “use additional code” does. The PDX should be assigned based on the circumstances of the admission. Below are some examples that may help you determine the PDX when COPD and pneumonia are both present and responsible for the admission.
COPD exacerbation and pneumonia specified only as community acquired:
Patient is admitted with COPD exacerbation and pneumonia. On admission the patient is started on IV antibiotics, oxygen, and IV steroids to taper. The patient does improve on this treatment plan and is discharged with the above diagnoses. In this case, both conditions did result in the inpatient admission and both were equally addressed/treated with IV medications. Per the 2019 ICD-10-CM Official Guidelines for Coding and Reporting, either of these conditions meets the definition of PDX.
COPD not in exacerbation and pneumonia:
Patient is admitted with pneumonia thought to be bacterial. There is no suggestion that the patients known COPD is in exacerbation. The patient is treated with IV antibiotics but no steroids. The patient improves and is discharged with the diagnosis of bacterial pneumonia, improved and history of COPD. In this case, the coder would report J15.9 (Unspecified bacterial pneumonia) as the PDX. J44.0 (Chronic obstructive pulmonary disease with lower respiratory infection would be sequenced as a SDX. In this case, the pneumonia is the condition that necessitated the admission and the condition that was aggressively treated.
References:
AHA Coding Clinic® for ICD-10-CM and ICD-10-PCS, Fourth Quarter 2017 Page: 96
ICD-10-CM Official Guidelines for Coding and Reporting FY 2019 Page: 103 – 107
cms.gov/Medicare/Coding/ICD10/2018-ICD-10-CM-and-GEMs.html
Happy Coding!
The information contained in this coding advice is valid at the time of posting. Viewers are encouraged to research subsequent official guidance in the areas associated with the topic as they can change rapidly.
Popular Posts
Coding Tip: Obstetric Tidbits for PCS
Last week, we looked at tidbits for reporting the ICD-10-CM codes for pregnancy/obstetric records. Now we will look at some for the ICD-10-PCS reporting of these records. In reporting the appropriate ICD-10-PCS codes a coder must know what is included in the terminology of products of conception (POC).
American Heart Month 2019
Chances are, we all know someone affected by heart disease and stroke, because about 2,300 Americans die of cardiovascular disease each day, an average of 1 death every 38 seconds. But together we can change that.
Coding Tip: Pregnancy, Childbirth, and the Puerperium Tidbits
There was a time when coding delivery records was considered simple. Many times, these types of records were given to the newer coders. However, as coding becomes more complex, this is no longer the case. With the implementation of ICD-10-CM came more codes for very detailed and specific issues that occur during pregnancy, childbirth and the puerperium.
Find Your Routine: Work Each Chart the Same Way
When it comes to coding and documentation, finding your own rhythm can lead to positive results. For our series, Find Your Routine, we interviewed our most productive coders and asked them what steps they take to find a rhythm that works for them. This week, we talked with Allison Curry, RHIT, CCS, Coding Specialist at Health Information Associates, about the steps she takes to find her routine.
Query Tip: Avoid Repetition in Clinical Indicators
One way to shorten a lengthy query is by avoiding repetition in the supporting documentation. Does the same diagnosis really need to be mentioned multiple times in the clinical indicators? Is it necessary to list the results of a chest x-ray twice? Does listing the same documentation multiple times give further specification or explanation to the query?
Subscribe to our weekly newsletter
Latest News
Coding Tip: Obstetric Tidbits for PCS
Last week, we looked at tidbits for reporting the ICD-10-CM codes for pregnancy/obstetric records. Now we will look at some for the ICD-10-PCS reporting of these records. In reporting the appropriate ICD-10-PCS codes a coder must know what is included in the terminology of products of conception (POC).
American Heart Month 2019
Chances are, we all know someone affected by heart disease and stroke, because about 2,300 Americans die of cardiovascular disease each day, an average of 1 death every 38 seconds. But together we can change that.
Coding Tip: Pregnancy, Childbirth, and the Puerperium Tidbits
There was a time when coding delivery records was considered simple. Many times, these types of records were given to the newer coders. However, as coding becomes more complex, this is no longer the case. With the implementation of ICD-10-CM came more codes for very detailed and specific issues that occur during pregnancy, childbirth and the puerperium.
Find Your Routine: Work Each Chart the Same Way
When it comes to coding and documentation, finding your own rhythm can lead to positive results. For our series, Find Your Routine, we interviewed our most productive coders and asked them what steps they take to find a rhythm that works for them. This week, we talked with Allison Curry, RHIT, CCS, Coding Specialist at Health Information Associates, about the steps she takes to find her routine.
Query Tip: Avoid Repetition in Clinical Indicators
One way to shorten a lengthy query is by avoiding repetition in the supporting documentation. Does the same diagnosis really need to be mentioned multiple times in the clinical indicators? Is it necessary to list the results of a chest x-ray twice? Does listing the same documentation multiple times give further specification or explanation to the query?
National Non-Smoking Week 2019
Tobacco use can lead to tobacco/nicotine dependence and serious health problems. Quitting smoking greatly reduces the risk of developing smoking-related diseases. Tobacco/nicotine dependence is a condition that often requires repeated treatments, but there are helpful treatments and resources for quitting.
Part 5 – New 2019 CPT Codes: Category III, Evaluation and Management, etc.
This is Part 5 of a five part series on the new 2019 CPT codes. For the remaining areas we will just briefly summarize the section. Due to the intricate nature of these sections in CPT, it is recommended that the coder read the entire section notes associated with the new codes.
Part 4 – New 2019 CPT Codes: Lymphatic, Digestive, Urinary and Nervous System
This is Part 4 of a five part series on the new 2019 CPT codes. In this series we will explore the CPT changes for FY 2019 and include examples to help the coder understand the new codes. There is 1 new lymphatic code, 2 new digestive system codes with 3 deletions, 3 new urinary system codes with one deletion and 7 deleted nervous system codes with 2 revisions.
Part 3 – New 2019 CPT Codes: Cardiovascular System
This is Part 3 of a five part series on the new 2019 CPT codes. In this series we will explore the CPT changes for FY2019 and include examples to help the coder understand the new codes. There are 9 new cardiovascular CPT codes added with 2 deletions and 3 revisions.
Find Your Routine: Know Your Client Workflow
When it comes to coding and documentation, finding your own rhythm can lead to positive results. For our series, Find Your Routine, we interviewed our most productive coders and asked them what steps they take to find a rhythm that works for them. This week, we talked with Tilina Sablan, RHIT, CCS, Coding Specialist with Health Information Associates, about the steps she takes to find her routine.
Part 2 – New 2019 CPT Codes: Musculoskeletal System
This is Part 2 of a five part series on the new 2019 CPT codes. In this series we will explore the CPT changes for FY2019 and include examples to help the coder understand the new codes. There are 4 new musculoskeletal CPT codes added with 2 deletions and 0 revisions.
Part 1 – New 2019 CPT Codes: Integumentary System
This is Part 1 of a five part series on the new 2019 CPT codes. In this series we will explore the CPT changes for FY2019 and include examples to help the coder understand the new codes. There were 15 new integumentary CPT codes added with 3 deletions and 1 revision.
Most Common DRG’s with Recommendations 2018: Part 5
In part 5 of our series, we look at DRG 64—Intracranial hemorrhage or cerebral infarction with MCC. For this DRG recommendation the majority (almost all) were recommended to DRG 65 (Intracranial hemorrhage or cerebral infarction with CC) with deletion of the reported MCC.
Most Common DRG’s with Recommendations 2018: Part 4
The majority of the recommendations from DRG 190 (Chronic obstructive pulmonary disease w/MCC) was to DRG 189 (Pulmonary edema and respiratory failure) with re-sequencing of respiratory failure as the PDX or adding as a new code and sequenced as PDX.
Most Common DRG’s with Recommendations 2018: Part 3
The majority of the recommendations from DRG 853 (Infectious & parasitic disease with O.R. procedure with MCC) were to DRG 871 (Septicemia w/o MV 96+ hours with MCC) with deletion or revision of the PCS code. Some of these required physician query.
Most Common DRG’s with Recommendations 2018: Part 2
The majority of the recommendations from DRG 872 (Septicemia w/o mechanical ventilation 96+ hours w/o MCC) were to DRG 871 (Septicemia w/o mechanical ventilation 96+ hours with MCC) with the addition of an MCC to the account. Not all of these required a physician query and were present in the medical record documentation without any clarification needed prior to coding.
Most Common DRG’s with Recommendations 2018: Part 1
The majority of the recommendations from DRG 871 (Septicemia w/o MV 96+ hours with MCC) were to DRG 872 (Septicemia w/o MV 96+ hours w/o MCC) with the recommendation to delete the reported MCC or query for clarification to support the MCC that had been reported.
Top 5 ICD-10 New Year’s Resolutions
Every year, we make plans to live a healthier, more organized, and balanced life. For some of us, we end up falling short of those expectations. This year, to keep us on track with our New Year’s goals, we have put together a few of the most common New Year’s resolutions along with their ICD-10 diagnoses codes. Check out our tips and tricks for a healthy 2019!
Top 5 ProFee Diagnosis Review Findings in 2018
Top 5 ProFee diagnosis changes found in recent HIA reviews: 1. I10 – Essential (Primary) Hypertension; 2. E11.9 – Type 2 Diabetes Mellitus Without Complications; 3. K29.60 – Other Gastritis Without Bleeding; 4. R13.19 – Other Dysphagia; 5. I25.10 – Atherosclerotic Heart Disease of Native Coronary Artery Without Angina Pectoris.
Coding Tip: Sequencing of the Principal Procedure
What is the principal procedure? The procedure that is performed for definitive treatment or is taking care of a complication is the principal procedure. Procedures for diagnostic or exploratory purposes that are performed in addition to a procedure being performed for definitive treatment, would be reported in addition to the principal procedure.
Query Tip: Avoiding a Leading Query – Don’t Be Directive
A query question that is directive in nature, indicating what the provider should document, rather than asking for his/her professional determination of clinical facts, constitutes a leading query. The provider should not be made to feel obligated to document anything.
Find Your Routine: Increase Reading Speed to Maximize Productivity
When I start coding a chart, I enter all account information in log and do any abstracting—disposition, admitting, and attending—take care of all of that first. ED, H&P, consult, progress reports, and discharge summary.
Speed Reading Tip: How to Increase Reading Speed
Some Speed Reading Tips: Once you start reading, don’t stop! Read the text straight through. If you have any question after you have completed reading the material, go back and reread the relevant sections. Reread the marked sections of the text (the items you indicated that you didn’t quite understand). Write a small summary at the beginning of the chapter – consisting about 3-4 sentences.
Coding Tip: Diagnosis Reporting for Routine Circumcision – Newborn
In HIA quality reviews we are finding that some coders are reporting Z41.2—Encounter for routine and ritual circumcision, during the male newborn birth admission, when circumcision is performed prior to discharge.
Coding Tip: GI Bleeding with Multiple Possible Sources
The cause/etiology of GI bleeding is not always easily determined. During procedures, to work the bleeding up, there are often multiple potential sources of bleeding found but not identified as the culprit. Many of these findings have “with” or “in” in the main or subterms.
Otis the Elf Visits HIA for Christmas 2018
On December 1, 2018, the HIA team based at our headquarters in Pawleys Island, South Carolina received a visit from a surprise guest – meet Otis, HIA’s very own Elf on a Shelf. Otis will be sticking around until Christmas to keep an eye on all of us. We have a feeling he may get into some trouble! Check back daily to see what Otis is up to. #OtisOnOtisDrive
Find Your Routine: Consistency is Key
When it comes to coding and documentation, finding your own rhythm can lead to positive results. For our new series, Find Your Routine, we interviewed our most productive coders and asked them what steps they take to find a rhythm that works for them. This week, we talked with Crystal Junkins, CCS, CPC, Coding Specialist with Health Information Associates, about the steps she takes to find her routine.
Coding Tip: What is COPD?
COPD is a respiratory condition where there is chronic obstruction to airflow in the lungs. Air is breathed into the lungs but a patient with COPD has trouble emptying air out of the lungs. This can also cause patients with COPD to have CO2 retention. COPD is an irreversible and progressive disease in which the lung function worsens as time goes on.
Query Tip: Query for Pathology Results
Tissue findings interpreted by a pathologist are not equivalent to the attending physician’s medical diagnosis based on the patient’s clinical condition. If the attending physician has not indicated the significance of an abnormal finding within a pathology report…