Chapter 10
DISEASES OF THE RESPIRATORY SYSTEM
Introduction
Diseases of the respiratory system are found in Chapter 10. This chapter includes conditions affecting the nose and sinuses, throat, tonsils, larynx and trachea, bronchi, and lungs. The chapter is organized by the general type of disease or condition and by site with diseases affecting primarily the upper respiratory system or the lower respiratory system housed in separate sections or blocks. The table below shows how this chapter is organized for each coding system.
ICD-10-CM Blocks
J00-J06
Acute Upper Respiratory Infections
J09-J18
Influenza and Pneumonia
J20-J22
Other Acute Lower Respiratory Infections
J30-J39
Other Diseases of Upper Respiratory Tract
J40-J47
Chronic Lower Respiratory Diseases
J60-J70
Lung Diseases Due to External Agents
J80-J84
Other Respiratory Diseases Principally Affecting the Interstitium
J85-J86
Suppurative and necrotic conditions of the lower respiratory tract
J90-J94
Other Diseases of the Pleura
J95
Intraoperative and Postprocedural Complications and Disorders of the Respiratory System, Not Elsewhere Classified
J96-J99
Other Diseases of the Respiratory System
Coding Note(s)
Chapter level instructions include a note related to reporting respiratory conditions occurring in more than one site and is not specifically indexed. In this instance, the code for the lower anatomic site is reported. The example given is a diagnosis of tracheobronchitis. Since there is no code for tracheobronchitis, the code for bronchitis (category J40) is reported. There is also a chapter level note related to using an additional code when there is documented exposure to tobacco smoke, history of tobacco use, or current tobacco use and dependence.
Exclusions
There is only an Excludes2 note for Chapter 10.
Excludes1
Excludes2
None
Certain conditions originating in the perinatal period (P04-P96)
Certain infectious and parasitic diseases (A00-B99)
Complications of pregnancy, childbirth and the puerperium (O00-O9A)
Congenital malformations, deformations and chromosomal abnormalities (Q00-Q99)
Endocrine, nutritional and metabolic diseases (E00-E88)
Injury, poisoning and certain other consequences of external causes (S00-T88)
Neoplasms (C00-D49)
Smoke inhalation (T59.81-)
Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R94)
Chapter Guidelines
There are several guidelines for Chapter 10. The guidelines cover COPD and asthma, acute respiratory failure and influenza. Guidelines for influenza are specific to influenza due to avian influenza virus. Finally, there are guidelines for ventilator associated pneumonia.
COPD and Asthma
Category J44 Other chronic obstructive pulmonary disease includes asthma with COPD. However, when reporting COPD with asthma, a second code from category J45 Asthma is required to identify the type of asthma. Codes in category J44 differentiate between uncomplicated cases and those with an acute exacerbation, which is a worsening or decompensation of a chronic condition. An acute exacerbation is not the same as an infection superimposed on a chronic condition, although an exacerbation may be triggered by an infection. This can be better understood by looking at the Includes, Excludes, Code also, and Use additional code notes in category J44. Under J44.1 Chronic obstructive pulmonary disease with (acute) exacerbation, there is an Excludes2 note indicating that COPD with acute bronchitis is reported with J44.0 Chronic obstructive pulmonary disease with (acute) lower respiratory infection. However, because this is an Excludes2, if the patient has an exacerbation triggered by the infection, then both codes (J44.0 and J44.1) are reported along with an additional code to identify the infection.
Acute Respiratory Failure
Guidelines for reporting acute respiratory failure (J96.0) and acute and chronic respiratory failure (J96.2) relate to sequencing of these codes. Sequencing guidelines are as follows:
•Acute or acute and chronic respiratory failure as principal diagnosis. Assign J96.0 or J96.2 as the principal diagnosis when:
–It is established after study to be chiefly responsible for occasioning the admission to the hospital
–Assignment of J96.0 or J96.2 is supported based on the Alphabetic Index and Tabular List
–Chapter specific guidelines such as those for obstetrics, poisoning, HIV, and newborns support the assignment of J96.0 or J96.2 as the principal diagnosis. If chapter specific guidelines provide different sequencing direction, the chapter specific guidelines take precedence
•Acute or acute and chronic respiratory failure as secondary diagnosis. Assign as a secondary diagnosis if:
–The condition occurs after admission
–The condition is present on admission but does not meet the definition of principal diagnosis
•Acute or acute and chronic respiratory failure and another acute condition:
–Sequencing will not be the same for every situation. This applies whether the other acute condition is a respiratory or non-respiratory condition
–Sequencing will be dependent on the circumstances of the admission
–If both conditions meet the definition of the principal diagnosis, either of the two conditions may be sequenced first
–If documentation is not clear as to which condition was responsible for the admission, query the provider
Influenza Due to Avian Influenza Virus (Avian Influenza)
There are three code categories for reporting influenza which are as follows:
•J09 Influenza due to certain identified influenza viruses:
–All codes in this category report influenza due to identified novel influenza A virus with various complications or manifestations such as pneumonia, other respiratory conditions, gastrointestinal manifestations, or other manifestations. Identified novel influenza A viruses include: avian (bird) influenza, swine influenza (2009 H1N1), influenza A/H5N1, and influenza of other animal origin (not bird or swine)
•J10 Influenza due to other identified influenza virus:
–This category includes Influenza A/H1N1 or H3N2 viruses that are not identified as variant or novel
•J11 Influenza due to unidentified influenza virus
Guidelines for reporting avian influenza are as follows:
•Code only confirmed cases of avian influenza and other certain identified or specific types of influenza reported with codes from category J09 and J10. This is an exception to the inpatient guideline related to uncertain diagnoses
•Confirmation does not require a positive laboratory finding. Documentation by the provider that the patient has avian influenza, or influenza due to other identified novel influenza A virus, is sufficient to report J09 Influenza due to certain identified influenza viruses
•Documentation of “suspected”, “possible”, or “probable” avian influenza or other novel influenza A virus is reported with a code from category J11 Influenza due to unidentified influenza virus
Ventilator Associated Pneumonia
Ventilator associated pneumonia (VAP) is listed in category J95 Intraoperative and postprocedural complications and disorders of respiratory system, not elsewhere classified. As with all procedural and postprocedural complications, the provider must document the relationship between the condition and the procedure. Guidelines for reporting VAP are as follows:
•Code J95.851 Ventilator associated pneumonia should be assigned only when the provider has documented the condition as VAP
•An additional code should be assigned to identify the organism (from categories B95-B97)
•Codes from categories J12-J18 are not assigned additionally to identify the type of pneumonia for VAP
•If the provider has not documented that a patient with pneumonia who is on a mechanical ventilator has VAP, do not assign code J95.851
•If the documentation is unclear as to whether or not the patient has VAP, query the provider
•VAP developing after admission is reported as a secondary diagnosis
•If the patient is admitted for one type of pneumonia and subsequently develops VAP, the appropriate code from J12-J18 is reported as the principal diagnosis and code J95.851 is reported as an additional diagnosis
General Documentation Requirements
When documenting diseases of the respiratory system there are a number of general documentation requirements of which providers should be aware. In this section we will discuss codes for acute recurrent conditions, combination codes, and intraoperative and postprocedural complications and disorders of the respiratory system.
Acute Recurrent Conditions
Acute sinusitis (J01.-) and acute streptococcal tonsillitis (J03.0-) differentiate between an acute unspecified condition and an acute recurrent condition. If the patient has an acute recurrent condition, documentation should specifically identify the condition as such. If the condition is not documented as acute recurrent, the default code for acute unspecified is reported.
Combination Codes
There are many combination codes for acute conditions and the infectious organism. Codes for acute bronchitis and acute bronchiolitis include the infectious organism.
There are also combination codes for influenza with specific manifestations. In categories J10 Influenza due to other identified influenza virus, and J11 Influenza due to unidentified influenza virus, associated complications and manifestations captured by the combination code include:
•Encephalopathy
•Gastrointestinal manifestations
•Myocarditis
•Otitis media
•Pneumonia
–With same other identified influenza virus pneumonia
–Other specified type of pneumonia
–Unspecified type of pneumonia
•Other respiratory manifestations
•Other specified manifestations
Intraoperative and Postprocedural Complications and Disorders of the Respiratory System
Most complications or disorders of the respiratory system occurring during or following a procedure are reported with codes listed in the respiratory system chapter. These codes are found in category J95. Complications and conditions reported with codes from this chapter include:
•Chemical pneumonitis due to anesthesia
•Complication of respirator or ventilator
–Mechanical
–Ventilator associated pneumonia
–Other complication
•Intraoperative
–Accidental puncture or laceration of a respiratory system organ or structure
»During a respiratory system procedure
»During a procedure not being performed on the respiratory system
–Hemorrhage or hematoma of a respiratory system organ or structure
»During a respiratory system procedure
»During a procedure not being performed on the respiratory system
–Other respiratory system complications, not elsewhere classified
Postprocedural
–Air leak
–Hemorrhage or hematoma of a respiratory system organ or structure
»Following a respiratory system procedure
»Following a procedure not being performed on the respiratory system
–Pulmonary insufficiency (acute or chronic)
»Following thoracic surgery
»Following nonthoracic surgery
–Pneumothorax
–Respiratory failure
–Subglottic stenosis
»Other respiratory system complications, not elsewhere classified
•Tracheostomy complications
–Hemorrhage from stoma
–Infection of stoma
–Malfunction of stoma
–Tracheoesophageal fistula
–Other tracheostomy complication
–Unspecified complication
•Transfusion related acute lung injury (TRALI)
Intraoperative and post-procedural hemorrhage/hematoma and laceration/puncture are specific to the procedure being performed. If the complication occurs during a procedure being performed on the respiratory system, code J95.61 is reported for hemorrhage/hematoma or code J95.71 for laceration/puncture. If the respiratory complication occurs during a procedure that is not being performed on the respiratory system, code J95.62 is reported for hemorrhage/hematoma or code J95.72 for laceration/puncture.
Postprocedural hemorrhage and hematoma follow a similar coding concept. Unlike intraoperative bleeding complications however, the postoperative complication separates hemorrhage and hematoma. Postprocedural hemorrhage of a respiratory system organ or structure following a respiratory system procedure is coded as J95.830 while a postoperative hematoma of a respiratory system organ or structure is coded as J95.860. Postprocedural hemorrhage of a respiratory system organ following a non- respiratory system procedure is coded as J95.831 and postprocedural hematoma as J95.861.
Code-Specific Documentation Requirements
While the documentation requirements for coding diseases of the respiratory system are not as extensive as those for diseases affecting other body systems, documentation requirements for some of the more commonly reported conditions do require additional information. In this section, the following conditions will be reviewed: acute sinusitis, acute bronchitis and bronchiolitis, viral and bacterial pneumonia, influenza, emphysema, asthma, bronchiectasis, acute respiratory distress syndrome, and acute and chronic respiratory failure.
Acute Bronchitis and Bronchiolitis
Bronchitis is an inflammation of the mucous membranes lining the bronchi. Bronchi are the large to medium-size airways that branch from the trachea carrying air to the lungs. Bronchitis may be acute or chronic. Acute bronchitis usually occurs with a viral or bacterial infection with symptoms that include cough with production of mucus.
Bronchiolitis is the inflammation and swelling of the mucous membranes lining the bronchioles, the smallest airways in the lungs. Bronchiolitis is most often caused by a viral infection and primarily affects infants and children under the age of 2 years. Symptoms can include productive cough, wheezing, tachypnea (fast breathing), nasal flaring, and intercostal retractions.
Codes for acute bronchitis (category J20) are combination codes specific to the infectious organism when the infectious organism is known. There is also a code for acute bronchitis, unspecified. Codes for acute bronchiolitis (category J21) include specific codes for acute bronchiolitis due to RSV, human metapneumovirus, and other specified organisms as well as a code for acute bronchiolitis, unspecified. Bronchospasm with either acute bronchitis or acute bronchiolitis is included in the code category.
Coding and Documentation Requirements
Identify condition:
•Acute bronchitis
•Acute bronchiolitis
Identify the organism:
•Acute bronchitis due to
–Mycoplasma pneumoniae
–Haemophilus influenzae
–Streptococcus
–Coxsackievirus
–Parainfluenza virus
–Respiratory syncytial virus (RSV)
–Rhinovirus
–Echovirus
–Other specified organisms
•Acute bronchiolitis due to
–Respiratory syncytial virus (RSV)
–Human metapneumovirus
–Other specified organisms
•Acute bronchitis, unspecified
•Acute bronchiolitis, unspecified
ICD-10-CM Code/Documentation
J20.0
Acute bronchitis due to Mycoplasma pneumoniae
J20.1
Acute bronchitis due to Haemophilus influenzae
J20.2
Acute bronchitis due to streptococcus
J20.3
Acute bronchitis due to coxsackievirus
J20.4
Acute bronchitis due to parainfluenza virus
J20.5
Acute bronchitis due to respiratory syncytial virus (RSV)
J20.6
Acute bronchitis due to rhinovirus
J20.7
Acute bronchitis due to echovirus
J20.8
Acute bronchitis due to other specified organisms
J20.9
Acute bronchitis, unspecified
J21.0
Acute bronchiolitis due to respiratory syncytial virus
J21.1
Acute bronchiolitis due to human metapneumovirus
J21.8
Acute bronchiolitis due to other specified organisms
J21.9
Acute bronchiolitis, unspecified
Documentation and Coding Example
Five-month-old female infant is brought to pediatrician’s office for worsening cold symptoms. According to mother, infant was well until 3 days ago when she developed clear nasal drainage and a cough. Both parents work and infant goes to a fairly large daycare center where many of the children have been sick this winter. Temperature 100.4, HR 122, RR 24, BP 70/54 O2 sat 96%. On examination, infant is alert and active, PERRL, TMs mildly red, not bulging. Copious clear nasal drainage, sample obtained and sent to lab for culture including rapid RSV antigen test. Oral mucosa moist and pink, pharynx red without exudates. Breath sounds have wheezes throughout, no distinct areas of consolidation. Mild intercostal retractions noted. Abdomen soft with active bowel sounds. Mother states baby has been breastfeeding and taking expressed breast milk from a bottle but has not been interested in solid food.
Chest x-ray obtained and shows few areas of hyperinflation and patchy infiltrates, some peribronchial cuffing. Nebulizer treatment with Xopenex and ipratropium bromide given with some improvement in respiratory symptoms, including decreased wheezing and retractions. Rapid RSV is positive.
Impression: RSV infection with bronchiolitis.
Plan: Discharge home with nebulizer loaner. Xopenex and ipratropium bromide q 4 hours. Continue breast feeding on demand. Tylenol for fever > 100 degrees. Parent advised to notify daycare of confirmed RSV so they can alert other parents if necessary.
Recheck scheduled for tomorrow afternoon. Parent given detailed explanation of signs and symptoms that would indicate respiratory compromise with instructions to call office or go to ED.
Diagnosis Code(s)
J21.0
Acute bronchiolitis due to respiratory syncytial virus
Coding Note(s)
For coding respiratory syncytial virus infection, assignment of the most specific code requires identification of the site/manifestation as bronchitis (J20.5), bronchiolitis (J21.0), or pneumonia (J12.1).
Asthma
Asthma is a chronic inflammatory condition that causes narrowing of the bronchi, which are the large upper airways connecting the trachea to the lungs. The disease is characterized by swelling, increased mucus production, and muscle tightness. Triggers can include allergens, smoke, exercise, stress, and respiratory infections. Genetic and environmental factors may contribute to asthma. Symptoms include cough, wheeze, chest tightness, and difficulty breathing.
Asthma is coded and reported as mild, moderate, or severe and then further differentiated as to whether it is uncomplicated, with acute exacerbation, or with status asthmaticus. Mild cases are further differentiated by whether they are documented as intermittent or persistent. Chronic obstructive asthma is not listed in the category for asthma but is under category J44 Other chronic obstructive pulmonary disease. Other forms of asthma include both exercise induced bronchospasm and cough variant with an additional code available for other specified types of asthma.
Coding and Documentation Requirements
Identify type of asthma:
•Mild
–Intermittent
–Persistent
•Moderate persistent
•Severe persistent
•Other specified type
–Exercise induced bronchospasm
–Cough variant
–Other
•Unspecified type
Identify complications (except for other specified types):
•Uncomplicated
•With acute exacerbation
•With status asthmaticus
Identify also tobacco exposure, use, dependence, or history of dependence
Asthma with Exacerbation
ICD-10-CM Code/Documentation
J45.21
Mild intermittent asthma with (acute) exacerbation
J45.31
Mild persistent asthma with (acute) exacerbation
J45.41
Moderate persistent asthma with (acute) exacerbation
J45.51
Severe persistent asthma with (acute) exacerbation
Documentation and Coding Example
Fifty-two-year-old Black female presents to ED with acute asthma episode. She is SOB, anxious, using accessory muscles in neck and chest to try and move air. Expiratory wheezes can be heard without using a stethoscope. Medications include Qvar, Singulair daily, and Xopenex last used 1 hour ago. HR 120, RR 22, BP 150/90. O2 saturation 92% on RA when she arrived and is now 95% on O2 4 L/m via mask that is also delivering Xopenex and Ipratropium bromide via nebulizer. IV started in left hand, 100 mg Solu-Cortef administered IVP. Patient is less anxious and able to speak in complete sentences following breathing treatment and oxygen therapy. She is placed on O2 via NC and maintains O2 saturation at 95%. Patient is able to give a medical history, which includes asthma/allergies since the age of 2. Triggers include animal dander, pollen, mold, cold weather, and URI. She has used oral and inhaled steroids extensively with documented osteoporosis on bone density study 2 years ago. Chest x-ray obtained and pneumonia is R/O.
Impression: Moderate persistent asthma with acute exacerbation most likely due to weather change/temperature drop.
Plan: Admit overnight for breathing treatments and IV steroids.
Diagnosis code(s)
J45.41
Moderate persistent asthma with (acute) exacerbation
Z79.51
Long term (current) use of inhaled steroids
Z79.52
Long term (current) use of systemic steroids
Coding Note(s)
Both extrinsic and intrinsic asthma are reported with codes from category J45. The code is selected based on the severity of the asthma, which in this case is documented as moderate. Long term use of steroids is differentiated as systemic use or inhaled use. Since the patient has used both types, codes for both are assigned.
Bacterial Pneumonia
Like many codes in Chapter 10, many of the pneumonias caused by bacteria have a combination code. The most common cause of bacterial pneumonia is Streptococcus pneumoniae, also called pneumococcal pneumonia. Lobar pneumonia of unspecified organism is not reported with the code for pneumonia due to S. pneumoniae (J13); it is reported with code J18.1 Lobar pneumonia, unspecified organism. Most of the more common types of bacterial pneumonia have specific codes. There are also a few bacterial causes of pneumonia that are classified in Chapter 1 Infectious and Parasitic Diseases, so it is important to use the Alphabetic Index to locate the correct code.
Mycoplasma pneumoniae is classified as bacterial pneumonia. Legionnaires’ disease is classified in Chapter 1 Infectious and Parasitic Diseases
Documentation and Coding Requirements
Identify the causative organism:
•Escherichia coli
•Haemophilus influenzae
•Klebsiella
•Legionnaires’ disease
•Mycoplasma
•Other (aerobic) gram negative
•Pneumococcal [streptococcus]
•Pseudomonas
•Staphylococcus
–Methicillin resistant
–Methicillin susceptible
–Other specified staphylococcus
–Unspecified staphylococcus
•Streptococcus
–Group B
–Pneumoniae [pneumococcal]
–Other specified/unspecified streptococci
•Other specified bacteria
•Unspecified bacteria
Identify any associated influenza, if applicable
Identify any associated abscess, if present
Bacterial Pneumonia
ICD-10-CM Code/Documentation
A48.1
Legionnaires’ disease
J13
Pneumonia due to Streptococcus pneumonia
J14
Pneumonia due to Haemophilus influenzae
J15.0
Pneumonia due to Klebsiella pneumoniae
J15.1
Pneumonia due to Pseudomonas
J15.20
Pneumonia due to staphylococcus, unspecified
J15.211
Pneumonia due to Methicillin susceptible Staphylococcus aureus
J15.212
Pneumonia due to Methicillin resistant Staphylococcus aureus
J15.29
Pneumonia due to other staphylococcus
J15.3
Pneumonia due to streptococcus, group B
J15.4
Pneumonia due to other streptococci
J15.5
Pneumonia due to Escherichia coli
J15.6
Pneumonia due to other Gram-negative bacteria
J15.7
Pneumonia due to Mycoplasma pneumoniae
J15.8
Pneumonia due to other specified bacteria
J15.9
Unspecified bacterial pneumonia
J18.1
Lobar pneumonia, unspecified organism
Documentation and Coding Example
Eighteen-month-old Caucasian male is brought into ED by EMS after suffering a febrile seizure at home. Grandparents provide a sketchy medical history as they are caring for the child while his parents are away. Attempts to contact the parents are being made. Grandparents state the child had a cough and congestion when they assumed care 2 days ago. He was a little tired and his appetite was decreased but he was taking fluids. Grandparents do not know if he has received childhood vaccinations. He seemed feverish this afternoon but there was no Tylenol or ibuprofen in the house so the grandmother gave him a sponge bath with cool water. A short time later he had a generalized motor seizure and since they are unfamiliar with the community they called 911 and an ambulance was dispatched. EMS crew states their ETA was 4 minutes and the child was unresponsive and still having a motor seizure when they arrived. He was administered Diastat in the field, intravenous line was placed, oxygen was started and he was transported to the ED. On arrival the child was sedated without seizure activity. T 104, P 116, R 18, BP 78/50, O2 saturation on O2 at 2 L/min via mask is 99%. Color pale, mucous membranes dry and pink. PERRLA. Throat red, without exudate. TMs pink but not bulging, fluid is visible in the left middle ear. Breath sounds are decreased in the left base, with scattered rales and wheezes throughout. He was administered acetaminophen 80 mg PR and cooling blanket applied. Blood drawn for CBC w/diff, metabolic panel and blood culture, LAT for Hib was also drawn given his unknown immunization status. Chest x-ray obtained and shows left lower lobe infiltrates.
Impression: Acute pneumonia.
Plan: Admit to PICU. Start IV Ampicillin, Gentamycin, and Ceftriaxone.
PICU Day 1: Afebrile with acetaminophen. Cooling blanket dc’d. No recurrence of seizure and EEG was WNL. LAT blood testing for Hib is positive, waiting for sensitivities on blood culture. O2 saturation 98% on RA, supplemental O2 discontinued. Continue antibiotic therapy. Advance diet as tolerated. Transfer to Pediatric Floor when bed is available. Repeat chest x-ray in AM.
Admit Day 2: Continues to do well. Repeat chest x-ray shows clearing infiltrates in lungs. Hib is sensitive to Ceftriaxone, Ampicillin and Gentamycin dc’d. Parents are at bedside.
Final Diagnosis: Pneumonia due to H. influenza, febrile seizure, underimmunization status.
Diagnosis Code(s)
J14
Pneumonia due to Haemophilus influenzae
R56.00
Simple febrile convulsions
Z28.3
Underimmunization status
Coding Note(s)
There is a combination code for the pneumonia due to H. influenzae. The febrile convulsion is reported additionally. Febrile convulsions are classified as simple or complex. If the febrile confusion is not specified as simple or complex, the default is simple. In this case, there is documentation describing the seizure as generalized motor seizure, the seizure lasted under 15 minutes, and did not recur within 24 hours. To be classified as complex, the seizure must last for more than 15 minutes, recur within 24 hours, or involve only one side of the body. So, the diagnosis would be simple febrile convulsions. The underimmunization status is also coded.
Bronchiectasis
Bronchiectasis refers to destruction and widening of the large airways. It most often occurs following recurrent, severe lower respiratory tract infection or inflammation. It may also occur following inhalation of a foreign object. Category J47 Bronchiectasis, differentiates between uncomplicated bronchiectasis and bronchiectasis with acute lower respiratory infection or exacerbation.
Coding and Documentation Requirements
Specify bronchiectasis and complications:
•With acute lower respiratory infection
•With exacerbation
•Uncomplicated
Identify tobacco exposure, use, dependence, or history of dependence
Bronchiectasis
ICD-10-CM Code/Documentation
J47.0
Bronchiectasis with acute lower respiratory infection
J47.1
Bronchiectasis with (acute) exacerbation
J47.9
Bronchiectasis, uncomplicated
Documentation and Coding Example
Twenty-six-year-old Caucasian male arrives in ED accompanied by Street Medicine Team. He is well known to the street doctors, works as a day laborer, lives out of his car, and is usually in good health. He has a history of tobacco use since late teens, smokes a few cigarettes a day when he can afford to buy them. He also drinks 1-2 beers almost daily. Temperature 100.8, HR 78, RR 18, BP 106/66, O2 saturation 95% on RA. On examination, this is a thin, ill-appearing young man with good hygiene, wearing clean clothes and well spoken. He states he was well until about 4 days ago when his normally dry, chronic cough became productive of yellow sputum. Today he is breathless and feels like he is drowning in secretions. PERRL, TMs clear. Neck supple. Breath is malodorous, teeth are clean and in good repair. Mucous membranes moist, pink. Nares patent with thin clear secretions. Oropharynx mildly red, moist with a cobblestone appearance. Heart rate regular without gallop or rub. No clubbing or cyanosis present. Breath sounds have fine scattered rales and wheezes on the right with decreased sounds in right middle and lower lobes. Left breath sounds are relatively clear and equal. Abdomen soft, non-distended. Bowel sounds present in all quadrants. Spleen is not palpated, liver is at the RCM. IV started in left arm and blood drawn for CBC, comprehensive metabolic panel, quantitative immunoglobulin levels. Sputum sent for analysis including gram stain, culture. Chest x-ray obtained and shows right lower lobe consolidation consistent with pneumonia. Patient will be admitted to medical floor for antibiotics and respiratory therapy. Pulmonology fellow requests high resolution CT scan of chest to further evaluate lung disease due to his history of tobacco use and chronic cough.
Pulmonology Note: CT scan shows bulbous appearing dilated bronchus on the right with areas of constriction and obstructive scarring. There is a postobstructive pneumonitis in the right middle and lower lobes of the lung. These findings are consistent with bronchiectasis exacerbated by acute lower respiratory infection. Preliminary sputum gram stain and culture positive for Klebsiella species, sensitive to current antibiotics.
Diagnosis code(s)
J15.0
Pneumonia due to Klebsiella pneumoniae
J47.0
Bronchiectasis with acute lower respiratory infection
Z72.0
Tobacco use
Coding Note(s)
In the documentation above, the ED physician has described the condition as pneumonia while the pulmonologist has described it as pneumonitis. In the Alphabetic Index under pneumonitis there is a note to “see also Pneumonia.” Since codes for acute bacterial lower respiratory tract infections are not listed under pneumonitis, the main term pneumonia is referenced for the correct code. The code for the pneumonia is the first listed or principal diagnosis because that is the condition that occasioned the ED visit. The bronchiectasis is a concurrent chronic condition that is reported additionally.
There is a code for reporting bronchiectasis with acute lower respiratory infection which is a complicating factor in bronchiectasis. There is a code also note for reporting tobacco use. Code Z72.0 is assigned rather than a code for tobacco dependence because there is no documentation indicating that the patient is dependent on tobacco.
Bronchitis/Chronic Bronchitis
Chronic bronchitis is an inflammation of the linings of the bronchi, also called the bronchial tubes, that has been present for more than a year with symptoms occurring most days of the month for at least three months. There are four categories of bronchitis that define non-acute bronchitis, J40 Bronchitis not specified as acute or chronic, J41 Simple and mucopurulent chronic bronchitis, J42 Unspecified chronic bronchitis, and J44 Other chronic obstructive pulmonary disease. Obstructive chronic bronchitis, is referred to as chronic obstructive pulmonary disease and is reported with codes in category J44. Conditions listed as included under category J44 are:
•Asthma with chronic obstructive pulmonary disease
•Chronic asthmatic (obstructive) bronchitis
•Chronic bronchitis with airways obstruction
•Chronic bronchitis with emphysema
•Chronic emphysematous bronchitis
•Chronic obstructive asthma
•Chronic obstructive bronchitis
•Chronic obstructive tracheobronchitis
Documentation and Coding Requirements
Identify type of non-acute bronchitis:
•Chronic
–Mixed simple and mucopurulent chronic bronchitis
–Mucopurulent
–Simple
–Unspecified chronic bronchitis
•Chronic obstructive pulmonary disease
–With acute lower respiratory infection
»Type of organism
–With (acute) exacerbation
–Unspecified
•Not specified as acute or chronic
Identify tobacco exposure, use, dependence, or history of dependence
Chronic Bronchitis
ICD-10-CM Code/Documentation
J40
Bronchitis, not specified as acute or chronic
J41.0
Simple chronic bronchitis
J41.1
Mucopurulent chronic bronchitis
J41.8
Mixed simple and mucopurulent chronic bronchitis
J42
Unspecified chronic bronchitis
J44.0
Chronic obstructive pulmonary disease with (acute) lower respiratory infection
J44.1
Chronic obstructive pulmonary disease with (acute) exacerbation
J44.9
Chronic obstructive pulmonary disease, unspecified
Documentation and Coding Example
Seventeen-year-old Black male presents to Urgent Care with 4 day history of fever and chills, shortness of breath, and a productive cough. The patient is well known to the clinic as he does community service and is mentored by a physician on staff. He plans to study medicine when he goes to college in the fall. Patient has a history of chronic asthmatic bronchitis from second hand smoke exposure. Current medications include Qvar Inhaler BID. T 101.8, P 100 R 22, BP 110/72, O2 Saturation on RA 95%. On examination, this is a thin, but muscular, well groomed, articulate but somewhat anxious young male. Eyes are clear, PERRLA. Nares patent with thin secretions, oral mucosa moist and pink. Posterior pharynx red, without exudate. Tonsils and adenoids are not enlarged. TM’s clear. Neck supple without lymphadenopathy. Apical pulse regular, peripheral pulses full but not bounding, no clubbing or cyanosis in extremities. Breath sounds have wheezes and scattered rales that do not clear with coughing, decreased sounds in the right middle and lower lobes. Abdomen soft with hypoactive bowel sounds. Liver palpated at 2 cm below the RCM, spleen at 1 cm below that LCM. He admits to decreased appetite x 2 days and mild nausea today. Cough is productive of thick, greenish mucous and a specimen is collected and sent to the lab. He was given an updraft treatment of albuterol and NS with supplemental O2 at 40%. O2 saturation improved during treatment and he was placed on O2 at 2 L/min via NC when it was completed. Chest x-ray obtained and shows changes consistent with chronic bronchitis and infiltrates in the right lung suggestive of pneumonia. IV started in right hand with LR infusing. Blood drawn for CBC, comprehensive metabolic panel, blood cultures. Gram stain of sputum shows gram negative rods. Suspect Pseudomonas infection. He will be admitted for updraft treatments and antibiotics.
In Patient Day 1: He remains febrile with temperature spike to 102.2. He is comfortable with ibuprofen and appetite is improving. Blood culture is negative at 24 hours. Sputum has heavy growth of P. aeruginosa, waiting for sensitivities. He continues to require oxygen at 2 L/min to maintain an oxygen saturation of >97%. Updraft nebulizer treatments of albuterol continue q 4 hours. Repeat chest x-ray confirms pneumonia in right middle and lower lobes. IV antibiotics of Tobramycin and Ampicillin will continue until sensitivities are back, consider monotherapy as soon as possible.
Final Diagnosis: Acute and chronic obstructive bronchitis with superimposed pneumonia due to P. aeruginosa.
Diagnosis Code(s)
J44.0
Chronic obstructive pulmonary disease with (acute) lower respiratory infection
J15.1
Pneumonia due to Pseudomonas
Z77.22
Contact with and (suspected) exposure to environmental tobacco smoke (acute) (chronic)
Coding Note(s)
Classifications for chronic bronchitis include a code specific for COPD with acute lower respiratory infection. The superimposed infection is due to P. aeruginosa which is a Pseudomonas infection so the code for pneumonia due to Pseudomonas is assigned. There is a use additional code note for exposure to environmental tobacco smoke so code Z77.22 is reported additionally to indicate a specified circumstance presenting hazards to health.
Emphysema
Emphysema is a type of chronic obstructive pulmonary disease (COPD) characterized by the slow destruction of elastic tissue forming the alveoli (air sacs) in the lungs. This leads to an increase in alveoli size and subsequent wall collapse with expiration which traps carbon dioxide in the lung and limits oxygen availability. Causes include smoking, pollution, and exposure to coal or silica dust. A genetic condition that causes a deficiency of the protein, alpha 1-antitrypsin, can also lead to emphysema. Symptoms include shortness of breath and cough.
There are five codes that differentiate between different morphological types of emphysema including: unilateral emphysema, also called MacLeod’s syndrome; panlobular emphysema, also called panacinar emphysema; and centrilobular emphysema, also called centriacinar emphysema. There are also codes for other specified type of emphysema, which would include paraseptal emphysema, and unspecified emphysema. Centrilobular emphysema begins in the bronchioles, spreads peripherally, involves primarily the upper half of the lungs, and is associated with long-term cigarette smoking. Panlobular emphysema destroys the entire alveolus, occurs primarily in the lower half of the lungs, and is seen primarily in individuals with a genetic condition that causes alpha1-antitrypsin (AAT) deficiency.
Coding and Documentation Requirements
Identify type of emphysema:
•Unilateral [MacLeod’s syndrome]
•Panlobular
•Centrilobular
•Other emphysema
•Unspecified emphysema
Identify tobacco exposure, use, dependence, or history of dependence
Emphysema
ICD-10-CM Code/Documentation
J43.0
Unilateral pulmonary emphysema [MacLeod’s syndrome]
J43.1
Panlobular emphysema
J43.2
Centrilobular emphysema
J43.8
Other emphysema
J43.9
Emphysema, unspecified
Documentation and Coding Example
Twenty-five-year-old Caucasian male presents to pulmonary specialist with a six-month history of left upper chest discomfort when flying and shortness of breath with physical exercise. Patient is an avid recreational pilot and had a recent physical to renew his pilot’s license, mentioned his symptoms to the examining physician who found them puzzling and suggested he see a lung specialist. Temperature 97.4, HR 60, RR 16, BP 110/60, O2 saturation 97% on RA. On examination, this is a well-developed, well-nourished pleasant young man. PMH is non-contributory. Usual childhood illnesses including colds, flu, strep throat, and infectious mononucleosis in high school. He does recall having a few URIs in the past year, the last about a month before he noticed the chest discomfort and SOB. Fingernails pink, good capillary refill, no clubbing. PERRL, neck supple without lymphadenopathy. Nares patent, mucous membranes moist and pink. Oral pharynx clear. TMs clear. HR regular without gallop or rub. Breath sounds are diminished on the left upper lobe with fine scattered rales throughout left lung fields. Patient denies pain at this time and describes the discomfort he has when flying as an achy tightness in left upper chest and back. PFT indicate mild obstructive pulmonary disease that improves with a bronchodilator. Chest x-ray shows unilateral hyperlucency of left lung, upper lobe. CT confirms hyperlucent left lung and shows a mediastinal shift to the right on inspiration and expiration.
Diagnosis: MacLeod’s Emphysema.
Plan: Sample of Spiriva inhaler and Singulair tablets given to patient with instruction for use. He will return in 2 weeks for repeat PFT and chest x-ray.
Diagnosis Code(s)
J43.0
Unilateral pulmonary emphysema [MacLeod’s syndrome]
Coding Note(s)
The documentation specifies the specific type of emphysema as MacLeod’s for which there is a specific code.
Influenza
Influenza is a common viral illness characterized by fever, chills, sore throat, headache, body aches, cough, and fatigue. Gastrointestinal symptoms such as nausea and vomiting may be present with some strains of the influenza virus. The virus is very contagious and is spread by respiratory droplets in the air, on contaminated surfaces, and via direct (person to person) contact with an infected individual. Complications of influenza can include pneumonia, bronchitis, and sinus and ear infections. Encephalopathy and myocarditis are rare complications.
There are three categories—J09 Influenza due to certain identified influenza viruses; J10 Influenza due to other identified influenza virus; and J11 Influenza due to unidentified influenza virus. There is no category or subcategory specific to the Type A/H1N1 virus, which is included within category J10. However, swine Influenza virus (viruses that normally cause infections in pigs) should be reported with a code from J09.X-. Codes are specific as to manifestations with codes for influenza with pneumonia, other respiratory manifestations, gastrointestinal manifestations, encephalopathy, myocarditis, otitis media, and other manifestations.
Coding and Documentation Requirements
Identify type of influenza and manifestations/complications:
•Novel influenza A virus
–With gastrointestinal manifestations
–With pneumonia
–With other respiratory manifestations
–With other specified manifestations, which includes:
»Encephalopathy
»Myocarditis
»Otitis media
•Other identified influenza virus
–With encephalopathy
–With gastrointestinal manifestations
–With myocarditis
–With otitis media
–With pneumonia
»With same other identified virus pneumonia
»With other specified type of pneumonia
»With unspecified type of pneumonia
–With other respiratory manifestations
–With other specified manifestations
•Unidentified type of influenza virus
–With encephalopathy
–With gastrointestinal manifestations
–With myocarditis
–With otitis media
–With pneumonia
»Specified type
»Unspecified type
–With other respiratory manifestations
–With other specified manifestations
Influenza
ICD-10-CM Code/Documentation
J09.X1
Influenza due to identified novel influenza A virus with pneumonia
J09.X2
Influenza due to identified novel influenza A virus with other respiratory manifestations
J09.X3
Influenza due to identified novel influenza A virus with gastrointestinal manifestations
J09.X9
Influenza due to identified novel influenza A virus with other manifestations
J10.00
Influenza due to other identified influenza virus with unspecified type of pneumonia
J10.01
Influenza due to other identified influenza virus with the same other identified influenza pneumonia
J10.08
Influenza due to other identified influenza virus with other specified pneumonia
J10.1
Influenza due to other identified influenza virus with other respiratory manifestations
J10.2
Influenza due to other identified influenza virus with gastrointestinal manifestations
J10.81
Influenza due to other identified influenza virus with encephalopathy
J10.82
Influenza due to other identified influenza virus with myocarditis
J10.83
Influenza due to other identified influenza virus with otitis media
J10.89
Influenza due to other identified influenza virus with other manifestations
J11.00
Influenza due to unidentified influenza virus with unspecified type of pneumonia
J11.08
Influenza due to unidentified influenza virus with specified pneumonia
J11.1
Influenza due to unidentified influenza virus with other respiratory manifestations
J11.2
Influenza due to unidentified influenza virus with gastrointestinal manifestations
J11.81
Influenza due to unidentified influenza virus with encephalopathy
J11.82
Influenza due to unidentified influenza virus with myocarditis
J11.83
Influenza due to unidentified influenza virus with otitis media
J11.89
Influenza due to unidentified influenza virus with other manifestations
Documentation and Coding Example
Patient is a 20-year-old female who presents to Urgent Care Clinic with worsening flu symptoms. Patient was seen one week ago for sudden onset of fever, chills, headache and was diagnosed with influenza. She was prescribed ibuprofen, fluids and rest, offered reassurance and sent home. Patient states her symptoms progressed with body aches, malaise, sore throat, and dry cough. Fever was gone by day 3 at which time she developed nasal congestion with copious clear drainage. Today she has fever of 102 and chills. Her cough is productive of thick white mucus. She has pain in her left lower rib area, worse with inspiration. Temperature 101.6, HR 94, RR 18, BP 98/52. Neck supple with palpable cervical and supraclavicular lymph nodes. Oral mucosa red with patchy white exudates, enlarged tonsils. HR regular without murmur, rub, gallop. Breath sounds decreased in left base, fine rales and wheezes throughout. Abdomen soft, non-distended. O2 sat 98% on RA. Chest x-ray shows scattered infiltrates in both lungs and an area of consolidation in left base.
Impression: Pneumonia secondary to influenza. Blood drawn for CBC. Sputum sent for culture. She is prescribed Azithromycin, advised to continue ibuprofen for pain and fever. RTC in 3 days for recheck and test results.
Diagnosis Code(s)
J11.00
Influenza due to unidentified influenza virus with unspecified type of pneumonia
Coding Note(s)
The influenza virus has not been identified nor has the type of pneumonia been identified so the correct code is for influenza due to an unidentified influenza virus with an unspecified type of pneumonia.
Respiratory Failure and Acute Respiratory Distress Syndrome
Respiratory failure and acute respiratory distress syndrome (ARDS) are two devastating conditions that affect the respiratory system. These conditions are found in separate categories and code blocks in Chapter 10 but will be discussed together here. Category code J80 Acute respiratory distress syndrome (ARDS) is listed in the code block J80-J84 Other Respiratory Diseases Principally Affecting the Interstitium. Category J96 Respiratory failure, not elsewhere classified is listed in code block J96-J99 Other Diseases of the Respiratory System and includes codes for respiratory failure documented as acute, chronic, acute and chronic, or unspecified except for those conditions in the newborn or when the respiratory failure is documented as postprocedural. Codes for respiratory failure are further differentiated by whether the condition is documented as with hypoxia, with hypercapnia, or whether there is no mention of hypoxia or hypercapnia.
Respiratory failure may occur when the respiratory system fails in one or both of its gas exchange functions: oxygenation and carbon dioxide elimination. It may be classified as either acute or chronic and as either hypoxemic or hypercapnic.
Hypoxemic respiratory failure, also referred to as Type I respiratory failure, is characterized by an arterial oxygen tension (PaO2) lower than 60 mm Hg with a normal or low arterial carbon dioxide tension (PaCO2) and is the most common form of respiratory failure. It is most often associated with acute diseases of the lung that involve fluid filling or collapse of alveolar units. Conditions that may result in hypoxemic respiratory failure include pneumonia, pulmonary edema, and pulmonary hemorrhage.
Hypercapnic respiratory failure, also referred to as Type II respiratory failure, is characterized by a PaCO2 higher than 50 mm Hg. Hypoxemia may be seen with hypercapnia in patients who are breathing room air. The duration of the hypercapnic respiratory failure affects the level of bicarbonate which in turn affects the pH. Common causes of hypercapnic respiratory failure include drug overdose, neuromuscular disease, chest wall abnormalities, and severe airway disorders, such as asthma and chronic obstructive pulmonary disease (COPD).
In order to understand these conditions better, definitions are listed below.
Acute Respiratory Distress Syndrome (ARDS): A life threatening condition caused by injury, inflammation, or infection of the lungs. It is characterized by low levels of oxygen in the blood and can occur alone or with systemic organ failure (heart, liver, kidney).
Acute Respiratory Failure: An acute condition characterized by low levels of oxygen and/or high levels of carbon dioxide in circulating blood caused by impaired exchange of gas (oxygen, carbon dioxide) at the alveolar level. The condition typically develops over minutes or hours.
Chronic Respiratory Failure: A chronic condition characterized by low levels of oxygen and/or high levels of carbon dioxide in circulating blood caused by impaired exchange of gas (oxygen, carbon dioxide) at the alveolar level. The condition typically develops over days, weeks, or months.
Acute and Chronic Respiratory Failure: These conditions may occur together when an individual with an underlying chronic condition causing low levels of oxygen and/or high levels of carbon dioxide in circulating blood develops an acute problem worsening the symptoms. For example: Respiratory failure in a patient with emphysema (chronic condition) with bacterial pneumonia (acute condition).
Hypoxia: Decreased levels of oxygen in circulating blood (PaO2 <60 to 80 mm Hg).
Hypercapnia: Increased levels of carbon dioxide in circulating blood (PaCo2 >50 to 55 mm Hg).
Coding and Documentation Requirements
Identify respiratory condition:
•Respiratory failure
•Respiratory distress or insufficiency
For respiratory failure, identify:
•Temporal factors
–Acute
–Chronic
–Acute and chronic
•Type
–With hypercapnia
–With hypoxia
–Unspecified whether with hypercapnia or hypoxia
Respiratory failure
ICD-10-CM Code/Documentation
J80
Acute respiratory distress syndrome
J96.00
Acute respiratory failure, unspecified whether with hypoxia or hypercapnia
J96.01
Acute respiratory failure with hypoxia
J96.02
Acute respiratory failure with hypercapnia
J96.10
Chronic respiratory failure, unspecified whether with hypoxia or hypercapnia
J96.11
Chronic respiratory failure with hypoxia
J96.12
Chronic respiratory failure with hypercapnia
J96.20
Acute and chronic respiratory failure, unspecified whether with hypoxia or hypercapnia
J96.21
Acute and chronic respiratory failure with hypoxia
J96.22
Acute and chronic respiratory failure with hypercapnia
J96.90
Respiratory failure, unspecified, unspecified whether with hypoxia or hypercapnia
J96.91
Respiratory failure, unspecified with hypoxia
J96.92
Respiratory failure, unspecified with hypercapnia
Documentation and Coding Example
Twenty-year-old Asian male referred to pulmonary clinic by his neurologist for nocturnal dyspnea and increasing daytime sleepiness. Patient was diagnosed with limb girdle muscular dystrophy 3 years ago with weakness impacting primarily the upper extremities. On examination, this is a small stature, thin young man, well-groomed and articulate. Temperature 98.6, HR 92, RR 20, BP 108/58, O2 Sat on RA 92 %. Color pale, skin warm, dry to touch. Mucous membranes moist and pale pink. TMs clear. Voice has a somewhat nasal quality. Nares patent, moist membranes without drainage. Mouth and throat are benign with no enlargement of lymph tissue. Neck supple. HR regular without murmur, an S3 gallop is appreciated. Patient had a routine EKG and echocardiogram 3 months ago which showed mild right axis deviation and right atrial enlargement. He is followed by cardiology q 6 months. Breath sounds decreased in bases but clear throughout. PFT shows a TV 0.24, VC 1.2, NIF-50. ABG on RA shows a pH 7.4, PaCO2 51, PaO2 65, HCO3 33, O2 Sat. 91%. Chest x-ray reveals basilar atelectasis. Patient is scheduled for a sleep study.
Sleep Study Note: Patient returns to clinic for sleep study. Procedure explained including possible use of non-invasive positive pressure nasal mask. A 6-hour monitored polysomnogram revealed 32 episodes of apnea and >200 periods of hypopnea with an average duration of 27 seconds. These occurred primarily during REM sleep with O2 saturation decreasing from an average of 82% to 35%. Nasal Bi-PAP was initiated during test with a marked improvement in O2 saturation and an 80% decrease in apnea and hypopnea episodes.
Impression: Chronic hypercapnic respiratory failure due to underlying neuromuscular disease complicated by sleep related hypoventilation.
Plan: Nasal Bi-PAP nightly. RTC in 1 month for recheck
Diagnosis code(s)
G71.09
Other specified muscular dystrophies
J96.12
Chronic respiratory failure with hypercapnia
G47.36
Sleep related hypoventilation in conditions classified elsewhere
Coding Note(s)
The cardiac conditions are not coded even though they are noted here, because the only problems being addressed are the pulmonary conditions.
While the patient does have decreased PaO2 levels, the code for respiratory failure with hypoxemia is not reported. According to the definition of hypercapnic respiratory failure, hypoxemia may be seen in a patient breathing room air. Also, the clinical indicator for hypoxemia is PaO2 less than 60-80. Since this is a range, and a diagnosis of hypoxemia is dependent on all the blood gas variables, some individuals might be considered hypoxemic at levels lower than 80 but other individuals may not be considered hypoxemic until PaO2 levels are below 60. Since the patient’s PaO2 is 65 which is still above the lower threshold for hypoxemia, and the physician has not diagnosed the patient as having respiratory failure with hypoxemia, the diagnosis is chronic respiratory failure with hypercapnia (J96.12).
Sinusitis
Sinusitis is an inflammation or infection of the nasal/accessory sinuses of the respiratory tract. The condition may be acute or chronic. Acute sinusitis is classified in category J01 and chronic sinusitis is classified in category J32. Both acute and chronic sinusitis are differentiated by site as maxillary, frontal, ethmoidal, or sphenoidal. There is a specific code for pansinusitis and a code for other sinusitis which is used to report sinusitis involving more than one sinus but not documented as involving all sinuses. In addition, acute sinusitis documented as recurrent has a specific code for each sinus. For acute sinusitis not specified as recurrent, the default is the unspecified code.
Documentation and Coding Requirements
Identify temporal factors:
•Acute
•Chronic
Identify affected sinus(es):
•Ethmoidal
•Frontal
•Maxillary
•Sphenoidal
•Pansinusitis
•Other acute/chronic sinusitis (includes more than one sinus but not pansinusitis)
•Unspecified acute/chronic sinusitis
Identify acute as recurrent or unspecified:
•Recurrent
•Unspecified (not recurrent)
Use additional code to identify infectious organism when documented.
For chronic sinusitis, use additional code to identify:
•Exposure to environmental tobacco smoke
•Exposure to tobacco smoke in the perinatal period
•History of tobacco use
•Occupational exposure to environmental tobacco smoke
•Tobacco dependence
•Tobacco use
Sinusitis
ICD-10-CM Code/Documentation
Acute Sinusitis
J01.00
Acute maxillary sinusitis, unspecified
J01.01
Acute recurrent maxillary sinusitis
J01.10
Acute frontal sinusitis, unspecified
J01.11
Acute recurrent frontal sinusitis
J01.20
Acute ethmoidal sinusitis, unspecified
J01.21
Acute recurrent ethmoidal sinusitis
J01.30
Acute sphenoidal sinusitis, unspecified
J01.31
Acute recurrent sphenoidal sinusitis
J01.40
Acute pansinusitis, unspecified
J01.41
Acute recurrent pansinusitis
J01.80
Other acute sinusitis
J01.81
Other acute recurrent sinusitis
J01.90
Acute sinusitis, unspecified
J01.91
Acute recurrent sinusitis, unspecified
Chronic Sinusitis
J32.0
Chronic maxillary sinusitis
J32.1
Chronic frontal sinusitis
J32.2
Chronic ethmoidal sinusitis
J32.3
Chronic sphenoidal sinusitis
J32.4
Chronic pansinusitis
J32.8
Other chronic sinusitis
J32.9
Chronic sinusitis, unspecified
Documentation and Coding Example
Twenty-two-year-old Hispanic female returns to clinic for follow up of sinusitis. Patient has a history of allergic rhinitis for which she uses Rhinocort AQ when her symptoms flare. She has had occasional episodes of sinusitis usually following URI that cleared with Zithromax, but this year she has had 4 episodes, the last one did not respond to the usual treatment. A CT scan one week ago showed consolidation with minimal air in the maxillary and ethmoid sinuses and blockage of the ostia consistent with acute sinusitis. A sterile tap of the maxillary sinus was performed with culture positive for H. influenzae and M. catarrhalis, both sensitive to Augmentin. Patient states she has been on the antibiotic for 3 days. On examination: T 98.8, P 68, R 14, BP 100/66. Conjunctiva mildly red and eyes have a clear, watery drainage. She continues to have tenderness in the eye orbits, upper jaw, and teeth. Nares swollen with scant amount of thick mucus, no polyps or septal deviation. Oral mucosa is moist and pink, posterior pharynx has a cobblestone appearance consistent with chronic allergies and thick purulent mucus coats the tissue. Neck supple with lymph node enlargement appreciated in the parotid, mandibular, and cervical areas. She denies problems swallowing but states she has completely lost her sense of smell. Breath sounds are clear and equal bilaterally.
Impression: Recurrent acute infection of the maxillary and anterior ethmoid sinuses due to H. influenzae and M. catarrhalis, on appropriate antibiotic therapy. Allergic rhinitis.
Plan: Continue Augmentin x 14 days. Patient has run out of her Rhinocort AQ and it is not covered by her new insurance. She is given samples of Flonase with instructions for use. She is also given an Rx for guaifenesin to take as needed for cough and congestion. RTC in 2 weeks, sooner if symptoms worsen or do not improve.
Diagnosis Code(s)
J01.81
Other acute recurrent sinusitis
B96.3
Haemophilus influenzae [H.influenzae] as the cause of diseases classified elsewhere
B96.89
Other specified bacterial agents as the cause of diseases classified elsewhere
J30.9
Allergic rhinitis, unspecified
Coding Note(s)
The acute sinusitis is documented as recurrent and is present in more than one sinus but not all four so the code for other acute recurrent sinusitis is assigned. There are two infectious organisms, both bacteria, that have caused the sinusitis. There is a specific code for the H. influenzae, but the M. catarrhalis must be reported with the other specified code because there is not a specific code for this organism. The physician has also diagnosed allergic rhinitis but has not specified the cause so the unspecified code is assigned.
Streptococcal Sore Throat
Streptococcal sore throat like many codes in Chapter 10 is classified as a combination code indicating the organism as well as the anatomic location. It is further classified based upon anatomic involvement of pharyngitis vs. tonsillitis. And finally, the codes are classified as to whether they are acute or recurrent.
Coding and Documentation Requirements
Identify condition:
•Pharyngitis
•Tonsillitis
For tonsillitis identify:
•Not recurrent/unspecified
•Recurrent
ICD-10-CM Code/Documentation
J02.0
Streptococcal pharyngitis
J03.00
Acute streptococcal tonsillitis, unspecified
J03.01
Acute recurrent streptococcal tonsillitis
Documentation and Coding Example
Patient presents with sudden onset of sore throat, headache, fever, and complaints of difficulty swallowing. Tonsils are red and enlarged. Rapid strep test positive. This is the third visit in the past three months for acute streptococcal tonsillitis. Prescription for ten-day course of antibiotics.
Diagnosis: Acute recurrent streptococcal tonsillitis
ICD-10-CM Diagnosis Code(s)
J03.01
Acute recurrent streptococcal tonsillitis
Viral Pneumonia
Pneumonia is an infection or inflammation of the lungs that can be caused by a variety of microorganisms including viruses, bacteria, fungi, and other microorganisms. Viral pneumonia may be caused by the influenza virus, viruses that cause the common cold (adenovirus, parainfluenza virus, and coronaviruses), and respiratory syncytial virus (RSV). Other less common causes of viral pneumonia include varicella and herpes viruses.
Specific codes exist for adenoviral pneumonia (J12.0), RSV pneumonia (J12.1), parainfluenza virus pneumonia (J12.2), and SARS-associated corona-virus pneumonia (J12.81). The latter is not the same as the newly discovered 2019 novel coronavirus that emerged in December of 2019 officially named “SARS-CoV-2”, causing “coronavirus disease 2019”, abbreviated COVID-19. This newer virus is genetically related to the virus causing the outbreak of SARS-associated coronavirus pneumonia in 2003, but causes a different illness and is currently reported with temporary code U07.1. Additionally, there is a specific code for human metapneumovirus (hMPV) pneumonia (J12.3).
Human metapneumovirus (hMPV) is a family of viruses that was first identified in 2001, but it most likely has been causing respiratory illnesses for decades worldwide. Human metapneumoviruses cause upper respiratory infections, such as colds, and lower respiratory tract infections, such as pneumonia or bronchitis in people of all ages. Most people with hMPV infection have mild upper respiratory symptoms including cough, runny nose, nasal congestion, sore throat, and fever. A small percentage of people will develop more serious lower respiratory illnesses. Most often those experiencing more serious illnesses are the very young, the very old, and immune compromised individuals.
Instructions for influenza complicated by pneumonia require reporting the appropriate influenza code first with an additional code for the pneumonia when the pneumonia is not caused by the influenza virus and the specific causative agent of the pneumonia is identified.
Documentation and Coding Requirements
Identify cause of viral pneumonia:
•Adenovirus
•Human metapneumovirus (hMPV)
•Parainfluenza virus
•Respiratory syncytial virus (RSV)
•SARS-associated coronavirus
•Other specified virus (excludes some viral infections complicated by pneumonia and influenza complicated by pneumonia caused by the same influenza virus)
•Unspecified
Note: Pneumonia caused by the 2019 novel coronavirus (COVID-19), is reported with codes U07.1 COVID-19 and J12.89 Other viral pneumonia.
Viral Pneumonia
ICD-10-CM Code/Documentation
J12.0
Adenoviral pneumonia
J12.1
Respiratory syncytial virus pneumonia
J12.2
Parainfluenza virus pneumonia
J12.3
Human metapneumovirus pneumonia
J12.81
Pneumonia due to SARS-associated coronavirus
J12.89
Other viral pneumonia
J12.9
Viral pneumonia, unspecified
Documentation and Coding Example
Forty-six-year-old Caucasian male presents to ED with a 3-day history of cough, congestion, and low grade fever. PMH is significant for renal failure on dialysis x 10 years with kidney transplant 18 months ago. He takes daily Imuran and Methylprednisolone to prevent rejection and Nexium for GI symptoms related to steroid use. Patient states he was seen yesterday by his PMD who diagnosed a viral URI and prescribed rest, fluids, and ibuprofen. He developed a sore throat, wheeze and shortness of breath in the past few hours and his PMD advised him to go immediately to the ED. On examination: T 99.8, P 90, R 20, BP 140/92, O2 saturation 92% on RA, increased to 98% on supplemental O2 at 4 L/min via NC. Alert, oriented, somewhat anxious adult male with mild respiratory distress. Breath sounds are decreased in bases bilaterally with scattered rales throughout the lungs that do not clear with coughing. Wheezing is appreciated over the bronchi. He is given a nebulizer treatment of Xopenex and budesonide with some improvement in air flow. IV started in left arm and blood drawn for CBC/diff, PT, PTT, metabolic panel, respiratory secretions for culture. D5W infusing at 100 cc/hr. Chest x-ray obtained and shows scattered infiltrates throughout right and left lungs consistent with a viral pneumonia.
Impression: Viral pneumonia in an immune compromised patient.
Plan: Admit to medical floor under care of Renal Transplant Service and Infectious Disease.
Inpatient Day 1: Stable. Continues to receive respiratory treatments of Xopenex and budesonide q 4 hours. Taking oral fluids but has nausea and no appetite. Remains on IV D5.45 NS with 10 mEq KCL. Suspect viral infection is caused by hMPV. Waiting for lab confirmation.
Inpatient Day 2: Lab confirms human Metapneumovirus infection. Repeat chest x-ray shows improvement with infiltrates in left and right bases and right middle lobe. Respiratory status much improved with breathing treatments q 6 hours and O2 saturation 98% on RA. Plan discharge tomorrow if he continues to improve.
Diagnosis Code(s)
J12.3
Human metapneumovirus pneumonia
Z94.0
Kidney transplant status
Z79.52
Long term (current) use of systemic steroids
Z79.899
Other long term (current) drug therapy
Coding Note(s)
There is a specific code for metapneumovirus pneumonia. The patient’s kidney transplant status is reported additionally as are the long-term use of systemic steroids and the long term use of the anti-rejection drug Imuran. There is not a specific code for long term use of Imuran so the other specified code is assigned.
Summary
Diseases of the respiratory system have fewer documentation requirements than other chapters, but the documentation requirements affect some of the more common conditions seen in the outpatient setting, including influenza, strep throat, and strep tonsillitis. Respiratory failure is another condition with significant documentation requirements. Capturing this complication requires an understanding of the definitions of acute and chronic respiratory failure and the difference between respiratory failure described as hypoxic or hypercapnic. If the patient has documentation of clinical laboratory values indicative of hypoxemia or hypercapnia, without specific documentation of respiratory failure, it will be necessary for coders to identify those values and query the physician to determine if a diagnosis of respiratory failure is warranted.
Resources
Documentation checklists are available in Appendix A for the following condition(s):
•Asthma
•Bronchitis/Bronchiolitis, Acute Infection
•Influenza
•Pharyngitis/Tonsillitis, Acute
•Pneumonia
Clinical indicator checklists are available in Appendix B for the following condition(s):
•Chronic Obstructive Pulmonary Disease
•Pneumonia
Chapter 10 Quiz
1.What factor influencing health status should be additionally coded when documented for diseases of the respiratory system?
a.The infectious organism
b.Other related health conditions
c.Any exposure to tobacco smoke or use of tobacco
d.All of the above
2.To assign the most specific code for asthma, which of the following documentation elements must be provided?
a.The condition must be described as acute or chronic
b.The asthma must be specified as mild, moderate, or severe
c.The condition must be specified as childhood asthma or adult asthma
d.The condition must be described as extrinsic or intrinsic
3.What acute conditions differentiate between an acute and an acute recurrent condition?
a.Paranasal sinusitis and streptococcal tonsillitis
b.Sinusitis, pharyngitis, and tonsillitis
c.Sinusitis and streptococcal pharyngitis
d.Sinusitis and unspecified upper respiratory infection
4.How is acute respiratory distress syndrome reported?
a.With a nonspecific code from category J96.9-Respiratory failure unspecified
b.With the code for acute respiratory failure unspecified whether with hypoxia or hypercapnia (J96.00)
c.With a code from block J80-J84 Other respiratory diseases principally affecting the interstitium
d.With code J99 Respiratory disorders in diseases classified elsewhere
5.Acute type I respiratory failure documented as present on admission is reported as follows:
a.As the first-listed or principal diagnosis using code J96.01
b.As a secondary diagnosis using code J96.01
c.As the first-listed or principal diagnosis using code J96.02
d.As the principal or a secondary diagnosis depending on the circumstances of the admission as documented by the physician using code J96.01
6.When chronic obstructive pulmonary disease (category J44) is complicated by viral pneumonia, the following coding guidelines and instructions are applicable:
a.The code for COPD with acute exacerbation is assigned (J44.1)
b.The code for COPD with acute lower respiratory infection is assigned along with a code identifying the organism (J44.0, B97.89)
c.The code for COPD with acute lower respiratory infection is assigned along with a code for the viral pneumonia (J44.0, J12.9)
d.The code for COPD with acute lower respiratory infection is assigned (J44.0)
7.A condition documented as severe persistent asthma with COPD is reported as follows:
a.J44.9 Chronic obstructive pulmonary disease, unspecified
b.J45.50 Severe persistent asthma, uncomplicated
c.J45.998 Other asthma
d.J44.9 Chronic obstructive pulmonary disease, unspecified and J45.50 Severe persistent asthma, uncomplicated
8.What additional information is required to assign the most specific code for lower respiratory syncytial virus infection?
a.The site/manifestation of the infection must be documented as bronchitis, bronchiolitis, or pneumonia
b.The infection must be documented as acute or subacute
c.RSV bronchitis or bronchiolitis must be documented as with or without bronchospasm
d.All of the above
9.Some manifestations of influenza are reported with a combination code. What manifestation does not need to be reported with an additional code for J09.X Influenza due to identified novel influenza A virus?
a.Gastrointestinal manifestations
b.Encephalopathy
c.Otitis media
d.Myocarditis
10.Streptococcal tonsillitis requires documentation as:
a.Acute or subacute
b.Acute or acute recurrent
c.Type A or Type B
d.Acute or other specified type
Chapter 10 Answers and Rationales
1.What factor influencing health status should be additionally coded when documented for diseases of the respiratory system?
c.Any exposure to tobacco smoke or use of tobacco
Rationale: Exposure to tobacco smoke and use of tobacco are classified as factors influencing health status and there is a note to use an additional code where applicable to identify these factors. While it may be appropriate to code the infectious organism and/or related health conditions, these are not considered factors influencing health status for coding purposes, so the only correct answer is c.
2.To assign the most specific code for asthma, which of the following documentation elements must be provided?
b.The asthma must be specified as mild, moderate, or severe
Rationale: The condition must be described as mild, moderate, or severe. It is also necessary to document any exacerbation and whether the condition is complicated by status asthmaticus. For mild asthma, it is also necessary to document the condition as either intermittent or persistent.
3.What acute conditions differentiate between an acute and an acute recurrent condition?
a.Paranasal sinusitis and streptococcal tonsillitis
Rationale: Paranasal sinusitis (maxillary, frontal, ethmoidal, sphenoidal, pansinusitis, other sinusitis, and unspecified paranasal sinusitis) and streptococcal tonsillitis require documentation of the acute condition as acute or acute recurrent. Acute pharyngitis, including streptococcal pharyngitis, does not have a separate code for acute recurrent conditions nor does an unspecified acute upper respiratory infection.
4.How is acute respiratory distress syndrome reported?
c.With a code from block J80-J84 Other respiratory diseases principally affecting the interstitium
Rationale: There is a specific code for acute respiratory distress syndrome (J80) that is listed in the code block J80-J84.
5.Acute type I respiratory failure documented as present on admission is reported as follows:
d.As the principal or a secondary diagnosis depending on the circumstances of the admission as documented by the physician using code J96.01
Rationale: Type 1 respiratory failure is another name for hypoxemic respiratory failure. When described as acute respiratory failure, it is reported with code J96.01. There should also be clinical documentation and blood gas values to support this diagnosis. Whether or not the condition is reported as the principal or a secondary diagnosis is dependent on the circumstances of the admission.
6.When chronic obstructive pulmonary disease (category J44) is complicated by viral pneumonia, the following coding guidelines and instructions are applicable:
c.The code for COPD with acute lower respiratory infection is assigned along with a code for the viral pneumonia (J44.0, J12.9)
Rationale: According to the coding guidelines, codes in category J44 differentiate between uncomplicated cases and those with an acute exacerbation, which is a worsening or decompensation of a chronic condition. An acute exacerbation is not the same as an infection superimposed on a chronic condition, though an exacerbation may be triggered by an infection. This is why there is a third option, code J44.0 COPD with (acute) lower respiratory infection. There is a note under J44.0 indicating that an additional code should be reported to identify the infection. In this case, the infection is specified as viral pneumonia so the J12.9 Viral pneumonia unspecified is reported. Nothing more is documented related to the viral pneumonia so it is not possible to identify the organism more specifically.
7.A condition documented as severe persistent asthma with COPD is reported as follows:
d.J44.9 Chronic obstructive pulmonary disease, unspecified and J45.50 Severe persistent asthma, uncomplicated
Rationale: The alphabetic index identifies J44.9 as the correct code. Under J44, there is a note to code also the type of asthma, if applicable. The asthma has been documented as severe, persistent asthma so code J45.50 is also reported.
8.What additional information is required to assign the most specific code for lower respiratory syncytial virus infection?
a.The site/manifestation of the infection must be documented as bronchitis, bronchiolitis, or pneumonia
Rationale: Assignment of the most specific code requires identification of the site/manifestation as bronchitis (J20.5), bronchiolitis (J21.0), or pneumonia (J12.1). The same code is used whether the condition is described as acute or subacute and whether it is described as with or without bronchospasm.
9.Some manifestations of influenza are reported with a combination code. What manifestation does not need to be reported with an additional code for J09.X Influenza due to identified novel influenza A virus?
a.Gastrointestinal manifestations
Rationale: Gastroenteritis is the only manifestation listed above that has a specific combination code (J09.X3) for influenza due to identified novel influenza A virus. The other three conditions are reported with code J09.X9 Influenza due to identified novel influenza A virus with other manifestations and require an additional code to identify the specific manifestation.
10.Streptococcal tonsillitis requires documentation as:
b.Acute or acute recurrent
Rationale: Codes are available for acute and acute recurrent streptococcal tonsillitis.