Q&A: COPD treatment for aspiration pneumonia and acute respiratory failure

Q: A patient with aspiration pneumonia and acute respiratory failure received treatment for chronic obstructive pulmonary disease (COPD), according to the physician documentation but there isn’t any documentation for clinical indicators for COPD. Should we be clarifying for this diagnosis? This scenario seems to be describes in AHA Coding Clinic for ICD-10-CM/PCS, but confused our CDI staff.

A: First of all, yes you should clarify the COPD diagnosis. Per the 2017 Official Guidelines for Coding and Reporting, a coder cannot elect to remove a diagnosis based on clinical indicators alone. However, before reporting a diagnosis with no documented indicators, a clarification query should be initiated for confirmation. 

Second, in cases of COPD and pneumonia, Coding Clinic, First Quarter 2016 instructs us to give priority to COPD as the principal diagnosis. However, if it was the pneumonia that prompted the patient’s admission to the hospital, and not the COPD, Coding Clinic conflicts with the Uniform Hospital Discharge Data Set (UHDDS) definition of a principal diagnosis.

The UHDDS guidelines supersede Coding Clinic. However, coding guidelines for COPD instruct us to “use additional code to identify the infection”. This led to the above Coding Clinic advice. I personally disagree with Coding Clinic because they are instructing us to add one of the B95 to B97 codes to identify the organism, if applicable. Clinically, I do not identify pneumonia as a type of organism that might be responsible for an infection in a COPD patient. Rather, the pneumonia is a clinical diagnosis in and of itself, which can occur with or without the presence of COPD. Therefore, pneumonia is not a sub-category of COPD.

We must go with what Coding Clinic says and hope the issues are sorted out in future guidance. For now, between COPD and pneumonia, as in the situation above, COPD would be the principal diagnosis.

To address the combination of COPD, pneumonia, and acute respiratory failure, Official Guidelines create further confusion:

“When a patient is admitted with respiratory failure and another acute condition, (e.g., myocardial infarction, cerebrovascular accident, aspiration pneumonia), the principal diagnosis will not be the same in every situation.”

Coding Clinic aimed to illustrate a scenario where the patient had a pre-existing respiratory condition (COPD) prior to getting pneumonia. In this case, a patient with both pneumonia and COPD, who presents with acute respiratory failure, certainly makes selecting the principal diagnosis more challenging.

As you might know, coders could view the respiratory failure as the result of the pneumonia and select pneumonia as the principal diagnosis. While I certainly understand—and sometimes even agree with that rationale—it is not so clear-cut here, since this patient (as they often do in the real world) has complex medical problems that, when properly understood, prevent you from pointing the finger at only the pneumonia and proclaiming the principle diagnosis is identified.

The pre-existing COPD actually gives further credibility to the choice of respiratory failure as the principal diagnosis. We know that both COPD and pneumonia are often treated in an observation or outpatient setting and do not always result in an inpatient admission.  However, respiratory failure would result in an inpatient admission.  Depending on the actual clinical data involved in the record, the principal diagnosis is subject to change based on the circumstances of the admission presented in the record. Remember, Coding Clinic examples are short vignettes, which make it hard to put all of the data from the original clinical record.

So in conclusion I really can’t give you a definitive answer to your question. We need to take into account the circumstances of the admission and every patient is different. The coding clinic tells us we would need to sequence the COPD prior to the pneumonia but there is no sequencing instruction related to the acute respiratory so either could actually be chosen. We need to look at the entire admission to determine the best choice.

Editor’s note: Allen Frady RN-BSN, CCDS, CCS, CDI Education Specialist for BLR Healthcare in Middleton, Massachusetts, answered this question. Contact him at AFrady@hcpro.com. For information regarding CDI Boot Camps visit http://hcmarketplace.com/clinical-doc-improvement-boot-camp-1.