Documenting & Coding. Chronic Obstructive Pulmonary Disease (COPD) Presented by: David S. Brigner, MLA, CPC
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1 Documenting & Coding Chronic Obstructive Pulmonary Disease (COPD) Presented by: David S. Brigner, MLA, CPC Sr. Provider Training & Development Consultant
2 Professional Profile David Brigner currently performs provider outreach coding consultation, education, and documentation training for Medicare Risk Adjustment payment methodologies on a national level. He has over 30 years of instructional expertise with educational institutions, health plans, hospitals, providers and administrative staff specializing in Health Information Management for various medical environments. On an academic level, Mr. Brigner has directed educational and training programs for several colleges and private educational institutions. He has constructed and maintained course curriculum specializing in Health Information Management, Medical Coding Systems and Health Insurance Claims Processing Mr. Brigner currently holds his Masters Degree in Administrative Leadership with emphasis in business leadership, marketing, nonprofit business management and communications. He is an active member of many professional and academic affiliations including American Academy of Professional Coders. David S. Brigner, MLA, CPC Sr. Provider Training & Development Consultant OptumInsight, Inc. 2
3 COPD Documentation to Support Documentation to Support COPD When reviewing a record with the diagnosis of COPD, identify the medical record documentation that substantiates COPD. Chest X-ray Arterial blood gases Pulmonary function tests Dyspnea, breathlessness, tachypnea Diffuse wheezing, diminished breath sounds, prolonged expiration Chronic productive cough Bronchospasm Hypoxemia Upper respiratory infection, airway inflammation Tachycardia Coding AHA Coding Clinic, third quarter 2002, p OptumInsight, Inc. 3
4 COPD Coding ICD-9-CM considers the following terms as having the same meaning with COPD Note: This statement above is not to be interpreted as saying that all of these statements listed below are to be coded to 496; it is stating that these items listed are various forms of COPD. COPD w/ Bronchitis Diffuse Obstructive Pulmonary Disease (chr.) Acute & Chronic Obstructive Bronchitis Bronchitis w/ Chronic Airway Obstruction Chronic Obstructive Lung DZ w/ Emphysema Bronchitis w/ Emphysema Emphysema w/ Chronic Bronchitis Emphysematous Bronchitis Blue Bloater Pink Puffer AHA Coding Clinic, third quarter 2002, p Ingenix, (2004). ICD-9-CM Changes; An Insider s View. p OptumInsight, Inc. 4
5 Coding COPD ICD9 Code Description HCC 108; RAF Simple Chronic Bronchitis (smokers cough) Mucopurulent Chronic Bronchitis Obstructed Chronic Bronchitis w/o Exacerbation Obstructed Chronic Bronchitis w/ (Ac) Exacerbation Obstructed Chronic Bronchitis w/ (Ac) Bronchitis Chronic Bronchitis, Other Chronic Bronchitis, Unspecified Emphysema, NOS Chronic Obstructed Asthma w/ Status Asthmaticus Chronic Obstructed Asthma w/ (Ac) Exacerbation 496 Chronic Airway Obstruction (COPD), NEC Ingenix, OptumInsight, Inc. 5 Inc. 5
6 COPD A Closer Look OptumInsight, Inc. 6
7 COPD - Overview COPD is a nonspecific term that encompasses many different respiratory conditions that cause progressive damage to the lungs. Such as: Bronchitis Bronchitis with emphysema Emphysema Asthma Only when COPD is documented in the absence of these conditions, is it coded as 496, Chronic airway obstruction, NEC: Chronic nonspecific lung disease Chronic obstructive lung disease Chronic obstructive pulmonary disease [COPD] NOS Ingenix 2011 ICD-9-CM Professional for Physicians. 6th ed. 2 Vols. USA: Ingenix, Print. OptumInsight, Inc. 7
8 COPD specified as/with: Chronic Bronchitis or Bronchitis w/ Emphysema (491) Obstructive Chronic Bronchitis x Emphysema (492) Emphysema x Asthma (493) Chronic Obstructive Asthma x OptumInsight, Inc. 8
9 COPD Coding Table COPD Description Special Alerts Code COPD Unspecified Chronic Airway Obstruction (COPD), NEC Should only be used when documentation does not specify the type of COPD and should not to be used with any other COPD code. 496 Obstructive Chronic Bronchitis Obstructive Chronic Bronchitis w/o Exacerbation Use for chronic airway obstruction; emphysema with chronic bronchitis Obstructive Chronic Bronchitis w/ (Acute) Exacerbation Documentation must support a worsening or a decompensation of the COPD condition to validate as an acute exacerbation; w/ or w/o emphysema Obstructive Chronic Bronchitis w/ Acute Bronchitis Use if documentation supports an infection superimposed on the COPD condition, or for acute bronchitis and exacerbation of COPD; w/ or w/o emphysema Chronic Obstructive Emphysema Emphysematous Bleb Use for giant bullous emphysema; ruptured emphysematous bleb; tension pneumatocele; vanishing lung Emphysema, Other, NOS Use for centriacinar; centrilobular; obstructive; panacinar; panlobular; unilateral; vesicular; unspecified or other emphysema Chronic Obstructed Asthma Chronic Obstructive Asthma, Unspecified Use for asthma with COPD or chronic asthmatic bronchitis, not specified as status asthmaticus or not specified as with (acute) exacerbation Chronic Obstructed Asthma w/ Status Asthmaticus Use for intractable asthma; refractory asthma; severe intractable wheezing; airway obstruction not relieved by bronchodilators; severe prolonged asthma attacks Chronic Obstructed Asthma w/ (Acute) Exacerbation A persistent form of acute asthma coexisting with COPD with labored breathing coupled with coughing and wheezing AHA Coding Clinic, 4th Q, Obstructive Chronic Bronchitis with Acute Bronchitis AHA Coding clinic, 1st Q, Diseases of the Respiratory System AHA Coding clinic, 3rd Q, COPD with Exacerbation OptumInsight, Inc. 9
10 Always Remember: COPD, NEC (496) COPD Code 496 Is a nonspecific code that should only be used when documentation does not specify the type of COPD, and should not be used with any other COPD code. 1, 2 OptumInsight, Inc AHA Coding Clinic (1984). Chronic obstructive pulmonary disease (COPD) guidelines. 2nd Quarter. 2 Ingenix (2011). Coders desk reference. Alexandria, VA: Ingenix, p. 429.
11 COPD with Bronchitis (491.20) Obstructive Chronic Bronchitis w/o (exac) HCC 108 Factor Assign when any of the following Note: diagnoses are documented w/o mention of an acute exacerbation: OptumInsight, Inc. 11 Emphysematous bronchitis Obstructive bronchitis Coding Clinic, fourth quarter 2008, pp Coding Clinic, third quarter 2002, p Ingenix, (2004). ICD-9-CM Changes; An Insider s View. p Bronchitis w/ chronic airway obstruction Consider smokers cough (491.0) with Tobacco use disorder (305.1) HCC 108
12 COPD with Bronchitis (491.21) Obstructive Chronic Bronchitis w/ (acute exacerbation) HCC 108 Factor Assign when any of the following diagnoses are documented w/ mention of an acute exacerbation: COPD w/ Exacerbation COPD w/ Acute Exacerbation Severe COPD in Exacerbation End-Stage COPD in Exacerbation Exacerbation of COPD Decompensated COPD Decompensated COPD w/ Exacerbation Special Note: Next slide OptumInsight, Inc. 12 Coding Clinic, fourth quarter 2008, pp Coding Clinic, third quarter 2002, p 18-19
13 COPD with Bronchitis (491.21) OptumInsight, Inc Obstructive Chronic Bronchitis w/ (acute exacerbation) Note: Documentation must support a worsening or a decompensation of the COPD condition to validate as an acute exacerbation. If documentation supports an infection superimposed on the COPD condition, then COPD with acute bronchitis (491.22) is plausible. COPD with exacerbation or acute exacerbation without mention of acute bronchitis is assigned to code If documentation supports acute bronchitis and exacerbation of COPD, assign only the combination code of COPD with acute bronchitis (491.22).
14 COPD with Bronchitis (491.22) Obstructive Chronic Bronchitis w/ (acute bronchitis) HCC 108 Factor Assign when any of the following diagnoses are documented w/ mention of an acute bronchitis: COPD w/ Acute Bronchitis Acute & Chronic Obstructive Bronchitis Emphysematous Bronchitis w/ Acute Bronchitis Emphysema w/ Acute & Chronic Bronchitis Obstructive Diffuse Pulmonary Disease w/ Acute Bronchitis Note: Acute bronchitis often exacerbates an existing COPD; therefore, the acute bronchitis supersedes or replaces the acute exacerbation. Note: COPD w/ Acute Exacerbation should not be used in such cases (AHA, Q-1, 2005) OptumInsight, Inc. 14 Coding Clinic, 2008, fourth quarter, pp Ingenix, (2004). ICD-9-CM Changes; An Insider s View. p 48-51
15 COPD with Bronchitis & Emphysema Obstructive Chronic bronchitis 491.2x Interrelationship Between Chronic Airway Obstruction, Chronic Bronchitis, and Emphysema Chronic airway obstruction (COPD, NOS) 496 Emphysema 492 Overlapping shaded areas: Obstructive Chronic Bronchitis (Chronic Bronchitis with COPD) These three conditions occurring together have been grouped into a single code category (491) Ingenix 2011 ICD-9-CM Professional for Physicians. 6th ed. 2 Vols. USA: Ingenix, Print. OptumInsight, Inc. 15
16 COPD with Asthma (493) OptumInsight, Inc XX COPD w/ Asthma HCC 108 Factor th and 5th digits are assigned to specifically indicate the type of asthma and w/ or w/o the presence of status asthmaticus, exacerbation or unspecified respectively: Extrinsic Asthma, Allergic w/ stated cause, Unsp. (i.e. Due to House Dust) (493.00) Extrinsic Asthma, w/ Acute Exacerbation (493.02) Intrinsic Asthma, Unsp. (493.10) Intrinsic Asthma, w/ Acute Exacerbation (493.12) Chronic Obst. Asthma, NOS (493.20) Chronic Obstr. Asthma, w/ (stat asth) (493.21) Chronic Obstr. Asthma w/ (ac exac) (493.22) Exercise Induced Bronchospasm (493.81) Cough Variant Asthma (493.82) Coding Clinic, 2008, fourth quarter, pp Ingenix, (2004). ICD-9-CM Changes; An Insider s View. p Note: Per ICD-9: Status asthmaticus refers to a patient s failure to respond to therapy administered during an asthmatic episode. If the patient is being treated with adrenal corticosteroids for asthmatic COPD, it must be clearly documented that status asthmaticus exists.
17 COPD with Asthma Chronic obstructive asthma (493.2x) Respiratory insufficiency is included in this subcategory; and should not be coded separately. COPD with Unsp. asthma (493.20) Unknown form of asthma coexisting with COPD COPD with status asthmaticus (493.21) Not relieved by bronchodilators and failure to respond to usual therapies Acute bronchitis (466.0) Is not included Code separately Emphysema (492.8) Is not included Code separately E/M Reminder: Medical Decision Making Number of diagnoses (or) management options Amount and/or complexity of data to be reviewed Risk COPD with (acute) exacerbation of asthma (493.22) A form characterized by a sudden, severe increase in severity Necessitates a 5th digit requiring specific documentation to indicate with the presence of status asthmaticus or acute exacerbation: Documentation must support a continuous asthmatic obstruction (COPD) to airflow with persistent restriction and labored breathing. Ingenix (2010). Coders desk reference. Alexandria, VA: Ingenix, p OptumInsight, Inc. 17
18 Emphysema Coding 491.2X, 492.x Emphysema 4 th and 5 th digits are assigned to specifically indicate the type of emphysema: Emphysematous Bleb (492.0) HCC 108; Factor Emphysema w/ Chronic Bronchitis (491.20) HCC 108; Factor Emphysematous Bronchitis w/ Acute Bronchitis (491.22) HCC 108; Factor Emphysema, NEC (492.8) HCC 108; Factor Acute Bronchitis w/ Emphysema (491.22) HCC 108; Factor Ingenix, (2004). ICD-9-CM Changes; An Insider s View. p OptumInsight, Inc. 18
19 Asthma & Empyema Coding 493.xx and 510.x Asthmas & Empyema 4 th and 5 th digits are assigned to specifically indicate the type of asthma w/ or w/o exacerbations (X), and empyema, w/ or w/o fistulas respectively (0,9): Asthma, Unspecified (493.9X) Cough Variant Asthma (493.82) Extrinsic Asthma (493.0X) Intrinsic Asthma (493.1X) Empyema w (fistula) (510.0) HCC 112; Factor (can be a result of emphysema) Empyema w/o (fistula) (510.9) HCC 112; Factor (can be a result of emphysema) Ingenix, (2004). ICD-9-CM Changes; An Insider s View. p OptumInsight, Inc. 19
20 Additional COPD Codes The following codes should be documented and coded if applicable: Hypoxemia (799.02) Dependence on respirator / ventilator, status (V46.11) Supplemental oxygen (V46.2) Long term oxygen therapy Code first the condition for which the patient is on oxygen (e.g. hypoxemia) Smokers cough (491.0) Tobacco use disorder (305.1) OptumInsight, Inc. 20 History of tobacco use (V15.82)
21 Additional Pulmonary Codes OptumInsight, Inc. 21
22 Additional Pulmonary Codes to Consider Malignant Neoplasm (of the lung; primary / secondary) (162.x; 197.x) (HCCs 7&8) - Also: Malignant pleural effusion ; Neoplasm, respiratory, of unsp. nature (no HCC s) Tracheostomy status (V44.0) (HCC 77) Attention to tracheostomy (V55.0) (HCC 77) Complications of tracheostomy (519.0x) (HCC 77) Complication respirator/ventilator (V46.14) (HCC 77) Respiratory arrest (799.1) (HCC 78) Pulmonary insufficiency (518.82) (HCC 79) Respiratory insufficiency (786.09) Respiratory failure (518.8x) (HCC 79) Pulmonary hypertension (416.8) (HCC 80) Chronic cardiopulmonary disease (Cor pulmonale) (416.9) (HCC 80) Postoperative respiratory complications (997.3x) (HCC 164) - Including: Ventilator Assisted Pneumonia (VAP) Lung transplant status (V42.6) (HCC 174) OptumInsight, Inc. 22
23 Pulmonary SX/sx Codes The following signs and symptoms are considered by ICD-9-CM as an integral part of the underlying pulmonary condition(s): They should not be coded unless there is no additional code assigned to indicate its presence. 1 Examples: OptumInsight, Inc. 23 Bronchospasm (519.11) Is an integral part of asthma or COPD Should only be assigned when the underlying condition has not been documented. Pleural Effusion, NOS (511.9) Is an integral part of pulmonary disease and some cardiac conditions. Should only be assigned when the underlying condition has not been documented. Other Pulmonary Insufficiency, NOS (518.82) (HCC 79) Is an integral part of any COPD code. Should only be assigned when the underlying condition has not been documented. Acute Pulmonary Edema, NOS (518.4) (HCC 79) Is an integral part of congestive heart failure This is not included in acute myocardial infarction, ischemic heart and atherosclerosis and should be coded separately if any of these conditions are present. 1 Brown, F. (2009). ICD-9-CM coding handbook AHA press, Atlanta, GA. pp
24 COPD Coding Examples (Summary) Example 1: Chronic obstructive bronchitis with acute bronchitis Obstructive chronic bronchitis with acute bronchitis. Rationale: Acute bronchitis often exacerbates an existing COPD; therefore, the acute bronchitis supersedes the acute exacerbation. Acute bronchitis (466.0) is not coded separately here Example 2: COPD with exacerbation , Obstructive chronic bronchitis, with acute exacerbation. Rationale: COPD with exacerbation without mention of acute bronchitis is assigned to code Example 3: Chronic obstructive bronchitis Obstructive chronic bronchitis without exacerbation. Rationale: The COPD with bronchitis without any further specification as acute or with exacerbation is assigned to code AHA Coding Clinic, 4th Q, Obstructive Chronic Bronchitis with Acute Bronchitis AHA Coding clinic, 1st Q, Diseases of the Respiratory System AHA Coding clinic, 3rd Q, COPD with Exacerbation Ingenix 2011 ICD-9-CM Professional for Physicians. 6th ed. 2 Vols. USA: Ingenix, Print. OptumInsight, Inc. 24
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