Graphic of human chest and lungs
Blog May 8, 2017

By Karen Newhouser, RN, BSN, CCM, CCDS, CCS, CDIP

Plans to End the COPD and Pneumonia Conundrum

Since the publication of two Coding Clinics in 3Q 2016 pg 15, Chronic obstructive pulmonary disease with lobar pneumonia, and pg 15-16, Acute exacerbation of chronic obstructive pulmonary disease with pneumonia, there have been many questions as to what appeared to be conflicts with several official guidelines. The Coding Clinics directed the coder to assign J44.0, Chronic obstructive pulmonary disease with an acute lower respiratory infection, as a principal diagnosis based on a “Use additional code to identify the infection.”

J44.1, Chronic obstructive pulmonary disease with (acute) exacerbation, was also directed to be coded as the principal diagnosis even though there is no “Use additional code…” note at that code index. Another concern regarding J44.1 is seen in the Alphabetic Index under Disease > Pulmonary (see also Disease, lung) > chronic obstructive > with, there are separate listings for ‘exacerbation (acute) J44.1’, and for ‘lower respiratory infection (acute) J44.0’, which created an either/or scenario for code selection when the documentation is a COPD exacerbation and a pneumonia.

These two coding clinics were confusing for several reasons. First, they seem in contradiction to the UHDDS guidelines for selection of principal diagnosis, which states, “The circumstances of inpatient admission always govern the selection of principal diagnosis. The principal diagnosis is defined in the Uniform Hospital Discharge Data Set (UHDDS) as “that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.” Many came forward to question why a chronic condition was being designated as the principal diagnosis when an acute condition was clinically the reason for admission.

Another area that is causing confusion regards I.A.13, Etiology/manifestation convention (“code first”, “use additional code”, and “in diseases classified elsewhere” notes), which requires a “code first” note at one half of a combination when the coder is aware of a “use additional code” note providing sequencing direction at the other half of a combination. While the majority of the combinations are etiology/manifestation codes, the last paragraph of this convention states, “Code first” and “Use additional code” notes are also used as sequencing rules in the classification for certain codes that are not part of an etiology/manifestation combination.” This last paragraph describes the COPD and pneumonia issue because we know that pneumonia is not a manifestation of COPD. That being said, there is no “code first” note at the pneumonia codes as required, which again left coding and CDI professionals scratching their heads.

The voices have been heard, for at the March 2017 Coordination and Maintenance committee meeting, it was recommended that the verbiage “Use additional code to identify the infection” be deleted, and replaced with “Code also to identify the infection.” This is significant because I.A.17, “Code also” note, states, “A “code also” note instructs that two codes may be required to fully describe a condition, but this note does not provide sequencing direction.” Essentially, this leaves the decision to the coder based on documentation surrounding the circumstances of the admission, and the UHDDS selection of principal diagnosis.

This change supports the already established conventions and guidelines surrounding principal diagnosis selection and emphasizes the point that our voices are heard; we only have to speak.



Coding Clinic. Third quarter, 2016, pg 15. Chronic obstructive pulmonary disease with lobar pneumonia. AHA.

Coding Clinic. Third quarter, 2016, pg 15-16. Acute exacerbation of chronic obstructive pulmonary disease with pneumonia. AHA.

ICD-10-CM Coordination and Maintenance Committee Meeting. Diagnosis agenda. March 7, 8, 2017. Pg 102. CDC. Retrieved from