2024 Coding Clinic 2nd Quarter: COPD and Z79

Chronic obstructive pulmonary disease, (COPD), is an overarching term for conditions which cause difficulty breathing, specifically from some type of impediment to air movement. The two main types are emphysema and chronic bronchitis. Both types can be present in the same patient. The most common etiology is tobacco exposure. It is a chronic, irreversible condition, although steps can be taken to prevent its progression.

Emphysema is characterized by small airway (i.e., bronchioles) and air sac (i.e., alveoli) losing their elasticity resulting in hyperinflation and impairment of exhalation. Air becomes trapped in the lungs, and gas exchange (i.e., oxygen and carbon dioxide) is compromised. Sometimes a portion of the lung becomes so thin-walled and distended that it forms what is called a pulmonary bleb or bulla, the distinction being size (1 cm is the cut-off). These cannot return to normal function and present the risk of rupture, causing a spontaneous pneumothorax.

Emphysema causes shortness of breath and deranged blood gases. It can be due to a genetic condition, although smoking is the most common precipitant. It can be further subdivided pathologically (hence J43 codes for panlobular or centrilobular, for instance), but providers often do not detail which of these subtypes is present.

Chronic bronchitis affects the airways, i.e., trachea, bronchi, and bronchioles. There is an increase in inflammation and mucus secretion in the lining of the airway which causes diminished airflow. It is manifested as a productive cough of more than 3 months in a 2-year period. The character of sputum in chronic bronchitis can vary between patients and vary over time in the same patient (e.g., simple, mucopurulent, mixed). A change in sputum production or color can indicate exacerbation or infection.

To round out the explanations, asthma is an obstructive pulmonary condition (and, even though it is chronic, it is not batched in “COPD”) which is often seen in children as well as adults. It results from bronchoconstriction and inflammation. The smooth muscle in the airways reacts to inflammatory mediators and causes bronchospasm. Asthma is often set off by a trigger, like an upper respiratory infection, exposure to pollutants, smoke, or fumes, or exercise. It is more rapidly reversible than a COPD exacerbation. Again, COPD and asthma can coexist in a patient.

The coding classification is already inaccurate in establishing an Excludes1 for chronic bronchitis (J41.-) and COPD. Chronic bronchitis is the specificity under the umbrella of COPD. The classification should allow for being able to use J44.0 or J44.1 to provide the specificity of status.

If a provider doesn’t know what type the patient has, they just state “COPD” in their documentation. That would result in use of J44.9, COPD, unspecified. The “unspecified” in the title isn’t REALLY for only for type, though, it is also for status. If there is an infection or exacerbation, then the “unspecified” term is eliminated and COPD with status (J44.0 or J44.1, or both) would be used.

2024 American Hospital Association Coding Clinic (CC) 2^nd quarter is advising that only J44.89, Other specified chronic obstructive pulmonary disease, should be assigned for verbiage of “asthma in a patient with COPD,” unless the clinician specifies the type of asthma or that the asthma is exacerbated. The J44 category was expanded in October 2023, and J44.89 was added.

I don’t really get this. First of all, this does not constitute specification of the COPD. The patient has two different conditions, COPD and asthma. Think of a childhood asthmatic who ignores the doctor’s advice, smokes, and develops chronic bronchitis. They have 2 different concomitant diagnoses. It may not be easy or even possible to sort out what component of an exacerbation is from COPD and what is from the asthma.

Furthermore, CC says “unspecified” is not considered a type of asthma. I would assert that “moderate persistent asthma, uncomplicated,” isn’t a TYPE of asthma; “Cough-variant asthma” might be considered a type. The initialism, “COPD” isn’t “specified,” either. Emphysema or chronic bronchitis are specified types of COPD.

In my opinion, the correct way to handle obstructive pulmonary disease would be (Please note, this is NOT the advice of CC or indexing!):

For COPD:

• A code indicating specific type of COPD, if known (e.g., emphysema or chronic bronchitis). Chronic bronchitis can also be subdivided into simple, mucopurulent, or mixed (as can emphysema be subcategorized, as noted above).
• If the COPD is in the context of a lower respiratory infection or if there is acute exacerbation, an additional code would be used to indicate that status

If no specificity or status were given, J44.9, Chronic obstructive pulmonary disease, unspecified, would be utilized.

For chronic asthmatic bronchitis, or asthma with COPD, or COPD with asthma (with no specificity of the COPD)

• J44.89, Other specified chronic obstructive pulmonary disease
• If the COPD is in the context of a lower respiratory infection or if there is acute exacerbation, another code (J44.0 or J44.1, or both) would be used to indicate that status
• A code to indicate the patient has asthma, too: [severity specific/ intermittent vs. persistent] asthma; either uncomplicated, with (acute) exacerbation, or with status asthmaticus. We always have to remember that “other specified” codes are a bucket for multiple different conditions. There is value to providing the asthma specificity.

I always advise, “As many codes as it takes” to detail a patient’s condition, and the combination of asthma and COPD is a good illustration.

Additionally, there is advice on Newly Prescribed Hypoglycemic Medication Intended for Long-Term Use on pages 26-27. The questioner wanted to know whether you should use Z79 code for the initiation of anti-diabetic hypoglycemic medication.

The question was a bit ambiguous to me. For example, was the coding being done in a facility where the patient was being evaluated for a possible stroke and the medication was being started for the new-onset diabetes or was it regarding coding at the rehab facility subsequently? It makes a difference to me.

Per the Coding Guidelines, if a medication is being administered for a brief period of time to treat an acute illness or injury, you don’t use a Z79, Long-term (current) use of medication code. If a patient is admitted in the hospital and wasn’t taking a medication prior to the encounter, I do not think it is appropriate to assign a Z79 code during that inpatient encounter for the newly prescribed medication, even if there is intention for the patient to remain on it long-term. I think they are conflating this with the guidance about G2211, the HCPCS add-on code to indicate an ongoing provider-patient relationship, which can be used even on the first visit. Antihypertensives, anticoagulation, steroids – if initiated during this inpatient admission, I don’t think Z79 is applicable…yet.

However, on the next visit, be it in the office, a readmission, or in the rehab facility, the Z79 code would be applicable. You are detailing “a patient’s continuous use of a prescribed drug for the long-term treatment of a condition or for prophylactic use.” The intent of the code is to register that the patient is taking a medication which could potentially have side effects or interactions. If they were just started on it today, that would not be a realistic concern.

Just to throw a little monkey wrench into this scenario, if a patient were in the hospital for a prolonged period of time, and they had a complication from that medication which was started during and administered throughout the hospitalization, and intended to be continued post-discharge, I WOULD use a Z79 code at discharge. It helps tell the story because your coding is trying to depict what happened with a patient during their hospital encounter.

As always, I recommend that you read the Coding Clinic for yourself. And remember, I am not a cooperating party, just an interested one!

Citation: AHA Coding Clinic, American Hospital Association, Volume 11, Number 2, Second Quarter, 2024, p. 3.