Q&A: Should COPD or pneumonia be sequenced as the principal diagnosis?

Q: If a patient is admitted with both pneumonia and chronic obstructive pulmonary disease (COPD), does pneumonia need to be coded before the COPD exacerbation? We have been coding COPD exacerbation first based on the advice given in AHA Coding Clinic, Third Quarter 2016, p. 15. Coding Clinic states that, when a patient is admitted with both COPD and pneumonia, the note under code J44.10, COPD with acute lower respiratory infection, instructs the coder to “use additional code to identify the infection.” Based on this, Coding Clinic J44.10 should be sequenced first. Is this correct?

A: The instructional note in the Coding Clinic referenced here was changed effective October 1, 2017. As a “code also,” either the pneumonia or the COPD may be sequenced first. The sequencing now depends on the circumstances of the encounter.

Looking at the UHDDS definition of a principal diagnosis as “that which is established after careful study as being chiefly responsible for occasioning the admission,” you will find that pneumonia is often the true principal diagnosis for a number of reasons.

One of the main reasons is pneumonia presents a greater risk to the patient for sepsis and respiratory failure than COPD does. It’s true that many simple pneumonia cases are managed on an outpatient basis, so I will not make a blanket statement that pneumonia must always be the principle diagnosis. Again, that determination will need to happen on a case by case basis depending on the circumstances of the encounter.

If inflammation and restriction are the primary motivating factors surrounding the decision to admit, then I may use COPD as the principal diagnosis. If infection and worsening infection response are the principal concerns, then I would likely choose the pneumonia.

Editor’s note: Allen Frady, RN, BSN, CCDS, CCS, CRC, CDI education specialist for HCPro 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.