Tip: Pneumonia with COPD

by Richard D. Pinson, MD, FACP

In its 2016 Third Quarter edition, the AHA’s Coding Clinic for ICD-10-CM/PCS clarified the use of the following two ICD-10 codes:

• J44.0:  Chronic obstructive pulmonary disease with acute lower respiratory infection
• J44.1:  Chronic obstructive pulmonary disease with (acute) exacerbation

Code J44.0 requires that the lower respiratory infection be sequenced after it, meaning the lower respiratory infection cannot be assigned as principal diagnosis in patients with COPD whether an acute exacerbation is present or not, as the code book states “use additional code to identify the infection.”

Controversy has swirled over whether pneumonia and influenza are classified as lower respiratory infections because Tabular entries seem to conflict. Includes notes at category J44 list only infections of the bronchial tree and not pneumonia or influenza.

J44-Other Chronic Obstructive Pulmonary Disease includes:

• Asthma with chronic obstructive pulmonary disease
• Chronic asthmatic (obstructive) bronchitis
• Chronic bronchitis with airways obstruction
• Chronic bronchitis with emphysema
• Chronic obstructive asthma
• Chronic obstructive bronchitis
• Chronic obstructive tracheobronchitis

However, the titles of ICD-10-CM acute respiratory infection categories suggest that pneumonia and influenza are lower respiratory infections since they are not "upper" respiratory infections and category J20-J22 is titled "other":

• J00-J06 = Acute Upper Respiratory Infections (includes tracheitis)
• J09-J18 = Influenza and Pneumonia
• J20-J22 = Other Acute Lower Respiratory Infections (bronchitis, bronchiolitis, and other)

Coding Clinic has settled the controversy by stating that acute bronchitis and pneumonia are included in code J44.0 (lower respiratory infections), but influenza is not since it involves both upper and lower respiratory infections.

Therefore, when a patient is admitted with pneumonia and has COPD, code J44.0 is coded first, followed by the code for pneumonia, and assigned to DRG 190 COPD with MCC.

• Pneumonia and AECOPD: When a patient has both pneumonia and acute exacerbation of COPD, it is appropriate to assign both codes J44.0, COPD with acute lower respiratory infection, and J44.1, COPD with (acute) exacerbation. Either of these codes may be sequenced first, based on the reason for the admission.
• Aspiration Pneumonia and COPD: Based on ICD-10-CM, aspiration pneumonia/pneumonitis is not an acute lower respiratory infection but rather classified as a lung disease due to external agents.  Therefore, if the patient has aspiration pneumonia and COPD, aspiration pneumonia J69.0 would be coded as principal diagnosis if it is the reason for admission, not J44.0.

Lung diseases due to external agents (J60-J70)

• J69 Pneumonitis due to solids and liquids (P24.-)
  
  • Excludes 1: neonatal aspiration syndromes and postprocedural pneumonitis (J95.4)
• J69.0 Pneumonitis due to inhalation of food and vomit
  
  • Aspiration pneumonia NOS
  • Aspiration pneumonia (due to) food (regurgitated)
  • Aspiration pneumonia (due to) gastric secretions
  • Aspiration pneumonia (due to) milk
  • Aspiration pneumonia (due to) vomit

Code also any associated foreign body in respiratory tract (T17.-)

In summary, like it or not Coding Clinic advice in this case is definitive since it provides official coding clarification when ICD-10-CM is ambiguous or conflicting. Even though pneumonia and influenza are classified together in ICD-10-CM, the issue is ambiguous and this Coding Clinic advice has a reasonable basis.

To enshrine this Coding Clinic advice about J44.0 in ICD-10-CM, it would seem prudent for the ICD-10 Coordination and Maintenance Committee to add an Includes note at J44.0 for the pneumonia code categories J12-J18 and for "other" lower respiratory infection categories J20-J22.

Keep in mind that ICD-10-CM clearly does not classify aspiration pneumonia (J69) as a lower respiratory infection and to do so would require adding it as an Includes note at J44.0. ICD-10-CM is not ambiguous or conflicting on this.

Editor’s Note: Pinson is a physician, educator, administrator, and healthcare consultant at Pinson & Tang. He practiced Internal Medicine and Emergency Medicine in Tennessee for over 20 years having board certification in both. He is also co-author of the best-selling CDI Pocket Guide and CDI for the Clinician™ e-learning program for physicians. Contact him at RPinson@PinsonandTang.com.