AHA Fourth Quarter Coding Clinic identifies problematic diagnosis codes.

Hopefully the subject of the most recently published Coding Clinic will not be too scary to discuss. It is effective for discharges from Oct. 1, 2017 forward.

The majority of this issue (94 of the 111 pages) provides some background to the new and revised ICD-10-CM/PCS codes for the 2018 fiscal year. Additional information on the new codes can be found in the Coordination & Maintenance Committee materials.

This article will focus on the guidance that is provided in pages 95-111. There are four subjects in particular cited in these pages.

Chronic Obstructive Pulmonary Disease (COPD)

When a patient has an exacerbation of COPD with influenza A, bacterial pneumonia, this scenario should be coded using J10.08 (influenza with specified pneumonia); J44.0 (COPD with lower respiratory infection); J15.9 (bacterial pneumonia); and J44.1 (exacerbation of COPD). The sequencing will be dependent on the patient’s presentation to the facility.

If the patient has COPD with acute exacerbation of asthma (unspecified), the case should be coded with J44.9 (COPD) and J45.901 (unspecified asthma with acute exacerbation) to fully describe the patient’s condition.

COPD with emphysema should be coded as J43.9 (emphysema), as emphysema is a form of COPD. Note: The Index has been updated to reflect that emphysema is a specified form of COPD.


A physician must document a relationship between any acute organ failure and sepsis. The coder can’t assume a relationship between sepsis and acute organ failure/dysfunction. Organ dysfunction/failure is needed to assign the code for severe sepsis. The coder can’t apply the recent changes to the coding guidelines regarding “with” and sepsis.

Uncertain Diagnosis

Coders should beware of physicians documenting diagnoses in the discharge summary that have been ruled out. “Uncertain diagnosis” at the time of discharge may be coded, but not any condition that has been ruled out, even if it has been investigated. The guidelines are clear about the coding of uncertain diagnosis; see the Official Guidelines for Coding and Reporting, Section II.H and Section III.C.

Unstageable Pressure Ulcer

Because this situation could be an inappropriate hospital-acquired condition (HAC), it is important to review. If a patient is admitted with an unstageable pressure ulcer because the ulcer is covered with eschar, which is removed to reveal the actual stage, code only the actual stage with the present-on-admission value of Y. The opening of the ulcer does not mean that the ulcer has progressed during the stay.

Coders will find that there is lots of valuable guidance in this new Coding Clinic edition, in addition to the new diagnosis and procedure codes.

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