Diseases of the Respiratory System (J00-J99) ICD-10 Sect IC Chap 10 Disease Respiratory 3-6-14

New terminology for asthma Respiratory condition in more than 1 site (not specifically indexed) classified to lower anatomic site Pay attention to additional code notes

Asthma Terminology Terminology used to describe asthma has been updated to reflect the current clinical classification of asthma The following terms have been added to describe asthma: Mild intermittent, and Three degrees of persistent – mild, moderate, severe

Asthma Coding J45.-- J45.2 Mild intermittent asthma J45.3 Mild persistent asthma J45.4 Moderate persistent asthma J45.5 Severe persistent asthma J45.9 Other and unspecified asthma

Symptoms Stage 1: mild Stage 2: moderate Stage 3: Severe Possible chronic cough and sputum production Stage 2: moderate Shortness of breath on exertion Stage 3: Severe Shortness of breath Fatigue Multiple exacerbations Reduced exercise tolerance GOLD = Global Initiative for Obstructive Lung dx Worldallergy.org ICD-10 Sect IC Chap 10 Disease Respiratory 3-6-14

Symptoms -2 Stage IV: Very severe Respiratory failure Elevation of jugular venous pressure Pitting ankle edema.

Respiratory condition in more than one site When a respiratory condition is described as occurring in more than one site and is not specifically indexed, it should be classified to the lower anatomic site For example, tracheobronchitis to bronchitis J40

Pneumonia J12-J18 Remember, if you know the organism code it! Default code = J18.9 Pneumonia, unspecified organism

Acute Bronchitis Category J20, Acute bronchitis, has been expanded to reflect the manifestations of the acute bronchitis For example, J20.2 Acute bronchitis due to streptococcus

Coding Guideline I.C.10.a.1. COPD and Asthma J44 – J45 Be sure to check Part I that the # are related to convention Acute exacerbation of chronic obstructive bronchitis and asthma An acute exacerbation is a worsening or a decompensation of a chronic condition An acute exacerbation is not equivalent to an infection superimposed on a chronic condition, though an exacerbation may be triggered by an infection

COPD and Emphysema J44 If resident has both COPD, NOS and emphysema, NOS, then one code is used J44.9

In the Tabular there is an Excludes 2 note under category J45 for asthma with chronic obstructive pulmonary disease. By definition, when an Excludes 2 note appears under a code, it is acceptable to use both the code and the excluded code together if the patient has both conditions at the same time.

Exercise #1 Patient was seen with high fever, cough, and chest pain. Diagnosis of diffuse bronchopneumonia was made. Gram stain of the sputum showed numerous small gram- negative coccobacilli. Diagnosis: H. influenza pneumonia What diagnosis is coded?

Answer #1 J14 Hypertension, hypertensive (accelerated) (benign) (essential) (idiopathic) (malignant) (systemic) Rational: The H. influenza pneumonia is coded to J14. The symptoms are not coded because they are inherent in the pneumonia code.

Exercise #2 Patient has increasing shortness of breath, weakness, and ineffective cough. Treatment included oxygen therapy and advice for smoking cessation. Diagnoses listed as acute respiratory insufficiency due to acute exacerbation of COPD and tobacco dependence. What diagnosis codes are assigned?

Answer #1 J44.1 Disease, diseased, pulmonary, chronic obstructive, with exacerbation (acute) F17.200 Dependence (on) (syndrome), tobacco – see dependence, drug, nicotine Z71.6 Counseling (for), substance abuse, tobacco Rational: The acute respiratory insufficiency is a symptom that is an integral part of the COPD and is not coded.

Exercise #3 Patient is being seen because of severe persistent asthma with acute exacerbation. What diagnosis codes are assigned?

Answer #3 J45.51 Asthma, asthmatic (bronchial) (catarrh) (spasmodic), persistent, severe, with exacerbation (acute) Rational: There are categories of the three degrees of persistent asthma, with the ability to identify with or without exacerbation and status asthmaticus.

Exercise #3 60-year-old male was admitted to the hospital with chest rales, dyspnea, cyanosis, and hypotension. He has severe gastroesophageal reflux causing him to aspirate food . He was treated for his aspiration neumonia with respiratory therapy and antibiotics. What diagnosis codes are assigned? What diagnosis codes are assigned?

Answer #3 J69.0 Pneumonia, aspiration, due to food (regurgitated) K21.9 Reflux, gastroesophageal  Rational: The chest rales, dyspnea, cyanosis, and hypotension are all symptoms of aspiration pneumonia and are not assigned codes. The gastroesophageal reflux contributed to the condition and should be coded.

Exercise #4 The physician has documented the following diagnoses for this elderly resident: COPD with emphysema, CHF, hypertension, and atrial fibrillation. What diagnosis codes are assigned?

Answer #4 J43.9 Emphysema (atrophic) (bullous) (chronic) (interlobular) (lung) (obstructive) (pulmonary) (senile) (vesicular) I50.9 Failure, failed, heart (acute) (senile) (sudden), congestive (compensated) (decompensated) I10 Hypertension, hypertensive (accelerated) (benign) (essential) (idiopathic) (malignant) (systemic)

Answer #4 -2 I48.0 Fibrillation, atrial or auricular (established) Rationale: Code J43.9 includes the COPD as indicated by the nonessential modifiers. Additionally, there is an Excludes1 note under J44 (COPD) for emphysema (J43.- ). Follow Index and Tabular carefully. When indexing COPD via Disease, lung, obstructive (chronic) there is a subterm with emphysema (J44.9). When verifying J44.9 in the Tabular there is an Excludes1 note: J44 Excludes1: emphysema without chronic bronchitis (J43.X). The emphysema in category J44 would be emphysema with chronic bronchitis.

Answer #4 -3 Rationale: When verifying J43.9 in the Tabular there is an Excludes1 note: emphysema with chronic (obstructive) bronchitis (J44.x). To differentiate these two categories with emphysema, chronic bronchitis is key and must be documented. In this case, follow the Tabular, not the Index.   The CHF and hypertension are coded with two codes since there is no stated causal relationship. ICD-10- CM Coding Guidelines state that if heart conditions (I50.-, I51.4 – I51.9) with hypertension do not have a documented causal relationship, the conditions are coded separately.

Exercise #5 Patient presented with gradual increase in shortness of breath, and was unresponsive to nebulizer treatments. At the time of admission, the theophylline level was 5.9. Chest x-ray showed no evidence of active infiltrates. The patient was bolused with intravenous steroids and started on frequent respiratory therapy treatments. IV aminophylline boluses and drip were used to increase his theophylline level to therapeutic range. Pt gradually cleared and the Ventolin treatments were decreased to q4 hr and his steroids were tapered back to 10 mg Prednisone.

Exercise #5 -2 Discharge diagnoses: What diagnosis codes are assigned? Moderate persistent asthma with status asthmaticus Acute exacerbation of COPD What diagnosis codes are assigned?

Answer #5 J45.42 Asthma, asthmatic, moderate persistent, with, status asthmaticus J44.1 Disease, lung, obstructive (chronic), with, acute, exacerbation NEC Rationale: An instructional note under category J44 provides instructions to “code also type of asthma, if applicable (J45.42).” An Excludes2 note appears under J45 for “asthma with chronic obstructive pulmonary disease.”

Answer #5 -2 Rationale: A type 2 “excludes note” represents “not included here.” An Excludes2 note indicates that the condition excluded is not part of the condition represented by the code, but a patient may have both conditions at the same time. When an Excludes2 note appears under a code, it is acceptable to use both the code and the excluded code together, when appropriate. The “code also” note does not provide sequencing direction.

Exercise #6 An elderly nursing home patient was seen for pneumonia. The patient has frequent aspiration pneumonia because of his difficulty in swallowing(neurogenic) due to a previous cerebral infarction. In addition to the aspiration-type pneumonia, the patient also has stage 1 decubitus ulcers on both his left and right hip. What diagnosis codes are assigned?

Answer #6 J69.0 Pneumonia, aspiration, due to food (regurgitated) Dysphagia, following, cerebrovascular disease, cerebral infarction R13.19 Dysphagia, neurogenic L89.211 Ulcer, decubitus – see Ulcer, pressure by site Ulcer, pressure, stage 1 (healing) (pre-ulcer skin changes limited to persistent focal edema), hip, right

Answer #6 -2 L89.221 Ulcer, pressure, Ulcer, pressure, stage 1 (healing) (pre-ulcer skin changes limited to persistent focal edema), hip, left

Answer #6 -3 Rationale: The documentation substantiates the assignment of aspiration pneumonia as the first listed diagnosis. The neurogenic dysphagia is due to an old cerebral infarction and should be coded. R13.19 is coded in addition to I69.391 due to an instructional note under I69.391 stating “Use additional code to identify the type of dysphagia, if known (R13.1-).” Two decubitus ulcer codes are required since the patient has ulcers of both the right and left hip. L89.211 is pressure ulcer of the right hip, stage 1 and L89.221 is pressure ulcer of the left hip, stage, 1.