The more things change, the more they stay the same. According to the latest Coding Clinic release (4th Quarter 2017), coders are once again allowed to sequence either COPD or pneumonia as the principal diagnosis depending on the circumstances of admission. This is a welcome change since it never really made sense from a coding and clinical perspective that COPD should be required to be sequenced first when a patient is admitted with both pneumonia and COPD (especially when COPD is not exacerbated).

Well, at least this is a moot point now, right? Not so fast – we have seen an uptick in denials from payers claiming that the correct sequencing rules for COPD and pneumonia were not followed. For reference, we thought it would be helpful to chronologically outline the rules and effective dates.

Coding Clinic – 3Q 2016: Pages 15-16 effective with discharges September 23, 2016

COPD with Lobar Pneumonia

• Per the instructional note, COPD must be sequenced as the principal diagnosis with lobar pneumonia assigned as an additional diagnosis

Acute Exacerbation of COPD with Pneumonia

• Either COPD with acute lower respiratory infection or COPD with exacerbation can assigned as the principal diagnosis
• Pneumonia must be assigned as an additional diagnosis

Acute Exacerbation of COPD with Acute Bronchitis 

• Assign COPD with acute lower respiratory infection as the principal diagnosis
• Assign acute bronchitis as a SDX

Lower Respiratory Infections included with COPD

• Lower respiratory infections include acute bronchitis and pneumonia and therefore must be sequenced as secondary diagnoses per the instructions in the ICD-10 tabular section
• Influenza is considered an upper and lower respiratory infection and therefore can be sequenced as the principal or secondary diagnosis

Coding Clinic – 1Q 2017: Page 24 effective with discharges March 13, 2017

Aspiration Pneumonia and COPD

• The instructional note for code J44.0 – COPD with lower respiratory infection to “Use additional code to identify the infection” does not apply to aspiration pneumonia because aspiration pneumonia is not categorized as a “respiratory infection”, it is included in the “lung disease due to external agents” section
• It is our interpretation of the guidance that it was always acceptable to assign aspiration pneumonia as the principal diagnosis when a patient is admitted with both COPD and aspiration pneumonia

Coding Clinic – 4Q 2017: Page 96 effective with discharges October 1, 2017

Bacterial Pneumonia, Influenza A & Acute Exacerbation of COPD

• The instructional note for code J44.0 – COPD changed from, “use additional code to identify the infection” to “code also to identify infection”
• Per the ICD-10 Official Coding Guidelines, a “Code Also, note instructs that two codes may be required to fully describe a condition, but this not does not provide sequencing direction. The sequencing depends on the circumstances of the encounter.”
• This instructional note change effectively allows coders to assign the principal diagnosis based on the circumstances of admission (i.e. coders can pick)
• More times than not, pneumonia will be selected as the principal diagnosis, just like it always has been

References
1. AHA Coding Clinic – 3rd Quarter 2016
2. AHA Coding Clinic – 1st Quarter 2017
3. AHA Coding Clinic – 4th Quarter 2017