Don’t Let COPD Diagnosis Coding Be an Endurance Test

By Renee Dustman
Mar 1st, 2015

Several conditions fall under COPD; understand how to code them all.

By Gouri Pathare, MBBS, CPC

Chronic obstructive pulmonary disease (COPD) refers to chronic bronchitis, emphysema, and alpha-1 antitrypsin deficiency, a genetic form of emphysema. Diagnosis coding and sequencing for COPD depends on physician documentation in the medical record and application of the official coding guidelines for inpatient care. You also may use American Hospital Association’s AHA Coding Clinic for ICD-9-CM and American Medical Association’s CPT® Assistant references to ensure complete and accurate coding.

Chronic bronchitis and emphysema are two distinct processes, often present in combination with chronic airway obstruction. Chronic bronchitis is associated with excessive tracheobronchial mucus production sufficient to cause cough with expectoration for at least three months of the year, for more than two consecutive years. Emphysema is defined as distension of air spaces distal to the terminal bronchial with destruction of alveolar septa. COPD is defined as a condition in which there is chronic obstruction to airflow due to chronic bronchitis or/and emphysema.

Coding Guidelines

When coding diagnoses of COPD, chronic bronchitis, acute bronchitis, chronic asthmatic bronchitis, acute asthmatic bronchitis, emphysema, etc., it’s important to understand the coding ramifications of the presence of two or more of these conditions, and whether the condition is acute, chronic, or in acute exacerbation.

COPD not elsewhere classified (ICD-9-CM code 496 Chronic airway obstruction, not elsewhere classified) is a nonspecific code that should only be used when the documentation in the medical record does not specify the type of COPD treated.

Acute Bronchitis/Asthma

Acute bronchitis with asthma is coded 466.0 Acute bronchitis and 493.90 Asthma, unspecified type, unspecified. The acute condition is sequenced before a chronic condition. Asthma is not documented as exacerbated, nor is the patient in status asthmaticus (AHA Coding Clinic for ICD-9-CM, fourth quarter 2004).

When coding acute bronchitis (466.0) and an exacerbation of asthma (493.92 Asthma, unspecified type, with (acute) exacerbation), code first the condition requiring the most care, or that is the major focus of care. An infectious process, such as acute bronchitis, is not equivalent to an acute exacerbation of asthma (AHA Coding Clinic for ICD-9-CM, fourth quarter 2004).

COPD with Acute Bronchitis

A diagnosis of COPD and acute bronchitis is classified to 491.22 Obstructive chronic bronchitis with acute bronchitis. It’s not necessary to assign code 466.0 (acute bronchitis) with 491.22. Code 491.22 is also assigned if the physician documents acute bronchitis with COPD exacerbation. If acute bronchitis is not mentioned with the COPD exacerbation, assign 491.21 Obstructive chronic bronchitis with (acute) exacerbation (AHA Coding Clinic for ICD-9-CM, fourth quarter 2008).

Acute Bronchitis/Emphysema/Chronic Obstructive Asthma

Acute bronchitis and emphysema are coded 466.0 and 492.8 Other emphysema. Acute bronchitis and chronic obstructive asthma are coded 466.0 and 493.2x Chronic obstructive asthma (AHA Coding Clinic for ICD-9-CM, volume 10, No. 5, and fourth quarter 1993).

Acute Exacerbation of COPD/ Bronchitis/ Asthma

Diagnoses of acute exacerbation of COPD, acute bronchitis, and acute exacerbation of asthma are coded 491.22 and 493.22 Chronic obstructive asthma with (acute) exacerbation (AHA Coding Clinic for ICD-9-CM, third quarter 2006).

COPD with Asthma

Asthma with COPD is classified to 493.2x.

Codes 493.0x Extrinsic asthma, 493.1x Intrinsic asthma, and 493.9x Asthma unspecified are used to classify asthma in patients without COPD. Be sure to review all coding directives in the Tabular List and Index to ensure appropriate code assignment. A fifth-digit sub classification is needed to identify the presence of status asthmaticus or exacerbation.

Report asthmatic bronchitis not specified as chronic with 493.90.


Bronchospasm is considered integral to asthma and COPD. Additional code 519.1x Other diseases of trachea and bronchus not elsewhere classified is not needed (AHA Coding Clinic for ICD-9-CM, third quarter 1988).

Chronic Bronchitis/Emphysema

Emphysema with chronic bronchitis is excluded from 492.8 Other emphysema. Use 491.20-491.22 (AHA Coding Clinic for ICD-9-CM, fourth quarter 2004).

Chronic Obstructive Bronchitis

An acute exacerbation of chronic obstructive bronchitis is coded 491.21 (AHA Coding Clinic for ICD-9-CM, fourth quarter 1991).

Chronic Obstructive Bronchitis/Emphysema/COPD

Chronic obstructive bronchitis and emphysema are forms of COPD. Chronic obstructive bronchitis with COPD and emphysema with COPD are redundant terms. COPD is not a separate disease entity (AHA Coding Clinic for ICD-9-CM, fourth quarter 1993).

Chronic Restrictive Lung Disease

Chronic restrictive lung disease is coded 518.89 Other diseases of lung, not elsewhere classified.

COPD on Anesthesia Evaluation

A diagnosis of COPD for an anesthesia evaluation signed by the anesthesiologist can be coded if there is no conflicting documentation in the medical record and you are certain COPD is a valid diagnosis (AHA Coding Clinic for ICD-9-CM, second quarter 2000 and second quarter 1992).

COPD/Complication of Surgery

If a patient with a history of COPD is admitted as an inpatient following outpatient surgery because of COPD exacerbation due to the procedure, assign 997.3 Respiratory complications not elsewhere classified as the principal diagnosis, with a secondary diagnosis of 491.21 (AHA Coding Clinic for ICD-9-CM, fourth quarter 1993).

Acute exacerbation of COPD (or acute exacerbations of chronic bronchitis) is a sudden worsening of COPD symptoms (shortness of breath, changes in quantity and color of phlegm) typically lasting for several days. Infection with bacteria or viruses or environmental pollutants may trigger acute exacerbation of COPD.

Emphysema/Respiratory Failure

A patient with emphysema is admitted to the hospital for acute respiratory failure. The principal diagnosis is 518.81 Acute respiratory failure (AHA Coding Clinic for ICD-9-CM, first quarter 2005).

Exacerbation of COPD

Exacerbation is defined as a decompensation of a chronic condition. It’s also defined as an increased severity of asthma symptoms, such as wheezing and shortness of breath. Although an infection can trigger it, an exacerbation is not the same as an infection superimposed on a chronic condition.

Status asthmaticus is a continuous obstructive asthmatic state unrelieved after initial therapy measures. If a physician documents both exacerbation and status asthmaticus in the same record, assign the fifth digit “1” to show the status asthmaticus. Sequence the status asthmaticus code first if documented with any type of COPD or with acute bronchitis (AHA Coding Clinic for ICD-9-CM, fourth quarter 2008).

COPD with exacerbation is classified to 491.21, which also includes:

  • Acute exacerbation of COPD
  • Exacerbation of COPD
  • Decompensated COPD
  • Decompensated COPD with exacerbation
  • COPD in exacerbation
  • Severe COPD in exacerbation
  • End-stage COPD in exacerbation

The word “acute” does not need to be documented to assign 491.21 for exacerbation of COPD (AHA Coding Clinic for ICD-9-CM, third quarter 2002). Per AHA Coding Clinic for ICD-9-CM (third quarter 1988), “When the acute exacerbation of COPD is clearly identified, it is the condition that will be designated as the principal diagnosis.”

Acute exacerbation of COPD, acute bronchitis, and acute exacerbation of asthma are classified to 491.22 and 493.22 (AHA Coding Clinic for ICD-9-CM, third quarter 2006).

Exposure to Tobacco Smoke/COPD

A physician’s diagnosis of an acute exacerbation of COPD with bronchitis, secondary to patient’s exposure to tobacco smoke due to 25 years of smoking, is coded 491.21 and 305.1 Tobacco use disorder (AHA Coding Clinic for ICD-9-CM, second quarter 1996).

Mucopurulent Bronchitis

Chronic or recurrent mucopurulent bronchitis is coded 491.1 Mucopurulent chronic bronchitis (AHA Coding Clinic for ICD-9-CM, third quarter 1988). Acute or subacute mucopurulent bronchitis is coded 466.0 (AHA Coding Clinic for ICD-9-CM, third quarter 1988; ICD-9-CM Index to Diseases).


Chronic obstructive bronchitis (491.20 Obstructive chronic bronchitis without exacerbation) and pneumonia (486 Pneumonia, organism unspecified) are always coded separately. Pneumonia is not an acute exacerbation of COPD (AHA Coding Clinic for ICD-9-CM, third quarter 1997). If  both asthma and pneumonia are present, each should be reported (AHA Coding Clinic for ICD-9-CM, first quarter 1992).

Respiratory Insufficiency/COPD

Respiratory insufficiency (518.82 Other pulmonary insufficiency, not elsewhere classified) is integral to COPD and should not be coded additionally with chronic obstructive bronchitis (491.2x), emphysema (492.x), chronic obstructive asthma (493.2x), or COPD (496) (AHA Coding Clinic for ICD-9-CM, second quarter 1991).

Secondary Diagnosis/COPD

Substantiation of COPD as a secondary diagnosis requires documentation in the medical record (history, treatment, anesthesiologist’s anesthesia evaluation, etc.) that the patient has COPD. Be sure to clarify with the physician any conflicting information (AHA Coding Clinic for ICD-9-CM, third quarter 2007, second quarter 2000, and second quarter 1992).

If the only mention of COPD is on an X-ray, the diagnosis should be clarified with the physician because COPD is found on many elderly patients’ chest X-rays when other clinical substantiation, treatment, or history of COPD is not present (AHA Coding Clinic for ICD-9-CM, second quarter 1990).

Steroid-dependent Asthma

Steroid-dependent asthma is coded to category 493 Asthma when there is no mention of a side effect due to the steroid therapy. When a side effect is mentioned, code both the asthma and the side effect. See Steroid in the ICD-9-CM Index to Diseases and the subentry for effects due to correct substance properly administered, 255.8 Other specified disorders of adrenal glands (AHA Coding Clinic for ICD-9-CM, July-August 1985).

ICD-9 Codes for COPD in Pregnancy

Pre-existing asthma or COPD complicating pregnancy, childbirth, or the puerperium is assigned two codes. First, assign 648.9x Other current conditions complicating pregnancy, childbirth, or the puerperium, followed by the COPD code.

COPD and ICD-10

Other Chronic Obstructive
Pulmonary Disease (COPD)

Includes asthma with COPD:

Chronic bronchitis with airway obstruction

Chronic bronchitis with emphysema

Chronic emphysematous bronchitis

Chronic obstructive asthma

Chronic obstructive bronchitis

Chronic obstructive tracheobronchitis

Code also type of asthma, if applicable (J45.-)

J44.0 Chronic obstructive pulmonary disease with acute lower respiratory infection

Use additional code to identify the infection.

J44.1 Chronic obstructive pulmonary disease with (acute) exacerbation

Decompensated COPD

Decompensated COPD with (acute) exacerbation

Chronic obstructive pulmonary disease with acute bronchitis J44.0

J44.9 Chronic obstructive pulmonary disease, unspecified

Chronic obstructive airway disease NOS

Chronic obstructive lung disease NOS

J45 Asthma 


Allergic (predominantly) asthma

Allergic bronchitis NOS

Allergic rhinitis with asthma

Atopic asthma

Extrinsic allergic asthma

Hay fever with asthma

Idiosyncratic asthma

Intrinsic non allergic asthma

Non allergic asthma

J45.2 Mild intermittent asthma

J45.20 Mild intermittent asthma, uncomplicated

Mild intermittent asthma NOS

J45.21 Mild intermittent asthma with (acute) exacerbation

J45.22 Mild intermittent asthma with status asthmaticus

J45.3 Mild persistent asthma

J45.30 Mild persistent asthma, uncomplicated

Mild persistent asthma NOS

J45.31 Mild persistent asthma with (acute) exacerbation

J45.32 Mild Persistent Asthma with status asthmaticus

J45.4 Moderate persistent asthma

J45.40 Moderate persistent asthma, uncomplicated

Moderate persistent asthma NOS

Moderate persistent asthma with (acute) exacerbation

Moderate persistent asthma with status asthmaticus

J45.5 Severe persistent asthma

J45.50 Severe persistent asthma, uncomplicated

Severe persistent asthma NOS

J45.51 Severe persistent asthma with (acute) exacerbation

J45.52 Severe persistent asthma with status asthmaticus

J45.9 Other and unspecified asthma

J45.90 Unspecified asthma

Unspecified asthma with (acute) exacerbation

Unspecified asthma with status asthmaticus

J45.909 Unspecified asthma, uncomplicated

J45.99 Other asthma

J45.990 Exercise induced bronchospasm

J45.991 Cough variant asthma

J45.998 Other asthma

Categories J44 and J45 distinguish between uncomplicated cases and those in acute exacerbation. An acute exacerbation is a worsening or a decompensation of a chronic condition. An acute exacerbation is not equivalent to an infection superimposed on a chronic condition, although an exacerbation may be triggered by an infection.

Assign J44.0 for COPD with acute bronchitis. Report J44.1 for the acute exacerbation of COPD. For acute exacerbation of asthma, report J45.901.


Gouri Pathare, MBBS, CPC, is a practicing medical professional with nearly 30 years of experience as an independent private medical practitioner in Mumbai, India, and has worked as a clinical specialist training coders for Episource India Pvt, Ltd., a U.S.-based KPO company.

ED Fracture Care Redux

By Renee Dustman
Mar 1st, 2015

Set the record straight when reporting global fracture care.

By Margie Scalley Vaught, CPC, COC, CPC-I, CCS-P, MCS-P, ACS-EM, ACS-OR, Robin Zink, CPC, and Barbara Fontaine, CPC

In the January issue of Healthcare Business Monthly, the article “Tricky ED Fracture Care Billing Explained” (pages 24-26) failed to provide all of the official documentation and sources regarding when to report a global fracture care CPT® code. Let’s clarify who should report a global fracture CPT® code and when.

Set the Record Straight

As coders, billers, administrators, providers, etc., it’s our job to know our various carrier and payer policies, and to follow them correctly. CPT® global fracture care codes have evolved over recent years, creating billing uncertainty. To make matters more confusing, CPT®, the Centers for Medicare & Medicaid Services (CMS), and private payer policies are not necessarily simpatico.

CMS, CPT®, the American Academy of Orthopaedic Surgeons (AAOS), and the American College of Emergency Physicians (ACEP) agree that an emergency department (ED) physician should not report a global fracture care code unless two situations occur:

  1. The ED physician is performing a “restorative” treatment, which has been interpreted to infer performing a reduction/manipulation of the fracture — not simply applying a splint/cast/brace; or
  2. The ED physician will be providing the global package to this patient, meaning he or she will provide follow up during the post-op period.

If these two situations are not present, the ED physician should only report the appropriate evaluation and management (E/M) CPT® code, and possibly the application of a cast/splint, if performed. No official source specifies the length of time between the ED visit and the follow-up care as a determining value for reporting a global code.

Learn by Example

CPT® Assistant, February 1996, provides this example:

Clinical vignette: Patient A presents to the emergency department after falling off a ladder. The emergency department physician determines that the patient’s left forearm is fractured. The physician then applies a short arm cast or splint and instructs the patient to follow up with an orthopedic physician.

To code the emergency department physician’s procedures for patient A, start with the two questions:

  1. Has the ED physician performed any restorative treatment or procedure(s) or is he or she expected to perform any restorative treatment or procedure(s)?
  2. Will the ED physician assume all subsequent fracture care?

In the case of Patient A, the answer to both questions is no. The emergency department physician is responsible only for the initial service of casting or splinting the fractured arm. He or she will not perform, and does not expect to perform, any restorative treatment. In addition, he or she will not assume all subsequent fracture care and has instructed the patient to follow up with an orthopedic physician.

Therefore, the emergency department physician reports code 29075 or 29125 for the application of the initial cast or splint. If the key components for the Evaluation and Management (E/M) codes are met, then also report the appropriate level of E/M with the 25 modifier appended.

CPT® Assistant, April 2002, provides another example:

ED physician evaluates a patient with ankle pain, confirms fracture but due to swelling applies a cast, and refers patient to orthopedic surgeon for treatment and follow-up care.

Does the patient’s condition require restorative treatment/procedure? YES

Will the same physician assume subsequent treatment and follow-up care? NO

The orthopedic surgeon evaluates the patient, reduces the fracture, applies a cast, and instructs the patient to return for follow-up care.

Does the patient’s condition require restorative treatment/procedure? YES

Will the same physician assume subsequent treatment and follow-up care? YES

Physician Service Modifier
ED Appropriate ED visit 25
ED Appropriate cast/strapping
OS Appropriate restorative treatment/procedure service (E/M and casting included in service)

The AMA also provides this example:

The ED physician sees a patient with a displaced Colles’ fracture. The ED physician performs a closed reduction to reduce the displacement and align the fracture, then applies a cast. She makes a referral for the patient to follow up with his family provider or orthopedic surgeon.

Does the patient’s condition require restorative treatment/procedure? YES

Was the restorative treatment/procedure performed by this provider? YES

Will the same physician assume subsequent treatment and follow-up care? NO

In this case, the ED physician did provide a restorative treatment/reduction/manipulation, and she should report the appropriate CPT® code (e.g., 25605 Closed treatment of distal radial fracture (eg, Colles or Smith type) or epiphyseal separation, includes closed treatment of fracture of ulnar styloid, when performed; with manipulation), with modifier 54 Surgical care only appended because she will not provide the subsequent treatment or follow-up.

Remember this advice from CPT® Assistant, February 1996:

Typically, the role of the emergency department physician is to treat an acute problem and refer the patient to a physician of a different specialty for subsequent treatment. In most cases, the emergency department physician will be responsible only for the initial care of a fracture that does not require immediate surgery (i.e., application of the first cast/strapping). The patient is then generally referred to an orthopedic physician for all subsequent fracture, dislocation, or injury care.


View the ACEP coding guidance for procedures in the ED.

For Medicare coverage policy on global periods, see the Medicare Claims Processing Manual, Pub. 100-04, chapter 12, section 40.


Margie Scalley Vaught, CPC, COC, CPC-I, CCS-P, MCS-P, ACS-EM, ACS-OR, has 30-plus years’ experience in the healthcare arena, from nurse’s aide to ward clerk and medical transcriptionist, to office manager. More than 25 of those years were spent in orthopaedics. Vaught stays current by attending the annual conventions for BONES, AAPC, MGMA, and AMA’s CPT® symposium. She also has provided testimony regarding correct coding issues and compliance in fraud and abuse cases. Vaught is a member of the Olympia, Washington, local chapter.

Robin Zink, CPC, has 34 years’ experience in the healthcare industry, having worked in various capacities in physician practice and hospital settings. Zink is the business office manager at Lancaster Orthopedic Group, where she has worked for the past 16 years. Her areas of expertise include revenue cycle management, coding, and regulatory compliance. Zink is a member of the Lancaster, Pennsylvania, local chapter.

Barbara Fontaine, CPC, has worked in medical offices for 30 years — the past 14 at Mid County Orthopaedic Surgery and Sports Medicine in St. Louis, Missouri. She serves as chair on the AAPC Chapter Association board. Fontaine is a member of the St. Louis West, Missouri, local chapter.

Reporting Rib Fracture Treatment in 2015

By Renee Dustman
Mar 1st, 2015

New codes require you to rethink code selection.

By G.J. Verhovshek, MA, CPC

CPT® 2015 radically changes how you report treatment of rib fractures this year. External fixation is now coded as an unlisted procedure, while open treatment options are defined by new codes and differentiated by the number of ribs involved.

Say Goodbye to Infrequently-used Treatment Options

CPT® 2015 deleted two rib fracture codes describing treatments used infrequently in current medical practice:

21800 Closed treatment of rib fracture, uncomplicated, each

Per CPT® instruction, you should now report closed treatment of an uncomplicated rib fracture using an appropriate evaluation and management (E/M) code, as determined by patient status (new or established), place of service (outpatient or inpatient), and documented level of care. A closed reduction means the fracture is set (reduced) using manipulation, without surgery.

21810 Treatment of rib fracture requiring external fixation (flail chest)

Open (surgical) treatment of rib fractures using internal fixation has become much more common than external fixation, and CPT® 2015 includes new codes to report these services (21811-21813). If the provider performs treatment of rib facture with external fixation, CPT® directs you to report unlisted procedure code 21899 Unlisted procedure, neck or thorax.

Say Hello to Category I for Open Tx with Internal Fixation

In previous years, open treatment of rib fracture using internal fixation was reported using CPT® Category III codes 0245T-0248T. Those codes are now deleted, replaced by Category I codes with similar descriptions:

21811 Open treatment of rib fracture(s) with internal fixation, includes thoracoscopic visualization when performed, unilateral; 1-3 ribs

21812 Open treatment of rib fracture(s) with internal fixation, includes thoracoscopic visualization when performed, unilateral; 4-6 ribs

21813 Open treatment of rib fracture(s) with internal fixation, includes thoracoscopic visualization when performed, unilateral; 7 or more ribs

As you may deduce from the code descriptors, code selection is based on the number of ribs treated. Thorascopic guidance is included, and may not be reported separately. Additionally, 21811-21813 are unilateral (single sided) procedures to which you may append modifier 50 Bilateral procedure, when appropriate.

Example 1: Using open treatment with internal fixation, the provider reduces fracture of three ribs on the left side. Proper coding is 21811.

Example 2: Using open treatment with internal fixation, the provider reduces fracture of four ribs on the left side and four ribs on the right side. Proper coding is 21812-50.

When reporting reduction by internal fixation, coding is less certain when an unequal number of ribs, described by distinct codes, are treated on opposite sides of the body. For instance, using open treatment with internal fixation, the provider reduces fracture of three ribs on the left side and five ribs on the right side. In such a case, a reasonable assumption would be to report the appropriate codes independently and apply anatomic modifiers LT Left side and RT Right side to specify laterality (e.g., 21811-LT and 21812-RT). But we all know what happens when one assumes. Perhaps a future edition of CPT® Assistant will address this issue.


G.J. Verhovshek, MA, CPC, is managing editor at AAPC, and a member of the Asheville-Hendersonville, North Carolina, local chapter.

Non-face-to-face Chronic Care Management Coverage Begins

By Renee Dustman
Mar 1st, 2015

You’re probably performing these services already, and now Medicare will reimburse you.

By Melissa Tescher, CPC, CPMA, CEMC

Effective January 1, 2015, Medicare pays for non-face-to-face services performed for chronic care management (CCM). This is great news because many providers already offer these services, and now they can be paid accordingly.

Medicare will pay $40.39, once per month, per patient for CPT® 99490 Chronic care management services, at least 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month, with the following required elements: multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient; chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline; comprehensive care plan established, implemented, revised, or monitored.

How to Capture This Revenue

CPT® 99490 is time-based: At least 20 minutes of documented clinical staff time is required to bill the code. When performing these management tasks, best practice is to document start and stop times, and include details of the coordination of care. Have a system in place to track patients and the time spent with them because this is a once-per-month code (see Care Management Log Sheet on page 15). Only one practitioner may bill for the service each month. To ensure your provider is the one who gets paid, bill 99490 on the same day that the minimum 20-minute time requirement is met.

The medical conditions of the patients must support the necessity of non-face-to-face work. As defined in CPT® 99490’s description, this requires:

  • The patient has two or more chronic conditions, which are expected to last at least 12 months or until the patient dies.
  • The chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline.
  • A comprehensive care plan is established, implemented, revised, or monitored.

Documentation is crucial because coding will be closely evaluated by payers to assess whether the service is targeted to the right population and the payment is appropriate for the furnished service.

Scope of Service and Documentation Requirements

CCM scope of service billing requirements include:

  • Structured recording of demographics, problems, medications, and medication allergies should be documented within a clinical summary record. The record must support the care plan, care coordination, and ongoing clinical care.
  • Patients must have access to care management services 24 hours a day, 7 days a week. They should easily be able to contact healthcare providers in the practice to address urgent chronic care needs, regardless of the day or time.
  • Patients should have continuity of care with a designated practitioner or member of the care team. Patients should be able to get successive routine appointments with someone familiar with them and their care plan.
  • CCM should include a systematic assessment of the patient’s medical, functional, and psychosocial needs, as well as system-based approaches to ensure timely receipt of all recommended preventive care services. Medication reconciliation with reviewing adherence and potential interactions and overseeing patients’ self-management of medications is necessary, as well.
  • A patient-centered plan based on physical, mental, cognitive, psychosocial, functional, and environmental (re)assessment should include an inventory of resources and supports, and a comprehensive care plan for all health issues. As appropriate, this plan should be accessible to other providers.
  • Provide patients with a written or electronic copy of their care plan, and document its provision in the medical record.
  • Manage care transitions between and among healthcare providers and settings, as necessary. This includes referrals to other clinicians, follow up after emergency department visits, and discharges from hospitals, skilled nursing facilities, or other healthcare facilities. Coordination with home- and community-based clinical service providers requires documenting in the patient’s medical record communication to and from home and community providers regarding the patient’s psychosocial needs and functional deficits.
  • Patients and caregivers should have enhanced opportunities to communicate with the practitioner through telephone access and secure messaging, Internet, or other consultation methods.

If all the above seems overwhelming, don’t worry: This service  likely already is being performed in your office. Documentation, as always, is the key. And to make the requirements less difficult, the Centers for Medicare & Medicaid Services has made an exception to the incident-to policy.

CCM services can be furnished incident-to if the services are provided by clinical staff (regardless of whether they are direct employees) under general — not direct — supervision of a practitioner, at any time. This is due to the non-face-to-face nature of the management services. Often, they occur at times before or after a clinic is open. It’s believed the requirement of a care plan ensures a close relationship between the practitioner and the clinical staff providing aspects of the CCM. This relationship is sufficient to render a requirement of a direct employment relationship or direct supervision unnecessary.

Make Patients Aware and Get It in Writing

Practices should inform patients of the availability of CCM services and obtain a signed agreement to provide the services before rendering them. This can be satisfied with a fact sheet that:

  • authorizes electronic communication of the patient’s medical information with other treating providers;
  • informs the patient of his or her right to stop CCM services at any time (effective at the end of the month);
  • explains the effect of agreement revocation on CCM services; and
  • makes the patient aware that only one practitioner can furnish and be paid for these services in any given month.

Keep the signed agreement in the patient’s medical record; and document in the medical record that all of the CCM services were explained and offered. Also note the patient’s decision to accept or decline these services.

Co-insurance will apply, and providers (or representatives) should explain the cost-sharing obligation to their patients.


Melissa Tescher, CPC, CPMA, CEMC, is compliance and coding specialist at Willamette Valley Professional Services in Salem, Oregon. She has been in the coding field over 10 years, with the last six spent auditing physician documentation and providing education to practitioners, support staff, and coding staff. Tescher enjoys speaking and mentoring at her local community college and at Salem, Oregon, local chapter meetings. She sits on the AAPC National Advisory Board.

Call on Combination Codes for Diabetes

By Renee Dustman
Mar 1st, 2015

Understand concepts that may or may not factor into ICD-10-CM code choices.

by Peggy Stilley, CPC, CPB, CPMA, COBGC

A major change when transitioning from ICD-9-CM to ICD-10-CM is the use of combination codes. In some cases, combination codes allow fewer codes to fully describe the patient’s conditions. Other combination codes require a secondary code to further describe the complication or the severity of the condition.

For example, diabetes mellitus is described using combination codes that include:

  • Type of diabetes
  • Body system affected
  • Complication affecting the body system

Diabetes includes five categories of ICD-10-CM codes:

E08 Diabetes mellitus due to underlying condition

E09 Drug or chemical induced diabetes mellitus

E10 Type I diabetes mellitus

E11 Type II diabetes mellitus

E13 Other specified diabetes mellitus (secondary, due to genetic defects, postprocedural)

Each type of diabetes provides a code for the complication or body system affected by the diabetes. ICD-10-CM coding guidelines in chapter 4 – Endocrine, Nutritional, and Metabolic Diseases – E00-E89 state that if the type of diabetes mellitus is not provided in documentation, the default is E11.-, type II diabetes.

Rethink Factoring Components

In ICD-10-CM coding, diabetes controlled or uncontrolled is not a concept; although, clinical documentation should provide the status of the patient’s condition and the response to treatment.

The concept of insulin dependent and non-insulin dependent is not a component in ICD-10-CM coding, either. You are instructed to report the long-term, current use of insulin for diabetic management in all categories of diabetes, with the exception of type I (E10).

You may report more than one diabetes code for patients with multiple complications or when multiple body systems are affected as a result of diabetes. This shows a more accurate view of the patient being treated, and could assist in supporting medical necessity, while showing complexity of medical decision-making.

Case No. 1

Patient presents with type I diabetes with no complications. Her sugars are well controlled with Lantus®, exercise, and diet. She will continue with same medication dosage, monitor glucose levels, and return in three months for recheck.

ICD-10-CM coding:

E10.9 Type I diabetes mellitus without complications

In this case, the patient has no complications, with normal sugars reported. The use of insulin is not reported with type I diabetes mellitus.

Case No. 2 

A 56-year-old, obese male with a long history of adult onset diabetes mellitus is seen for a follow-up evaluation. He has no new symptoms. He has been dependent on insulin for 10 years, and has stage 2 diabetic chronic kidney disease (CKD). He does not keep his calories or diet in range.

Vitals: Weight: 245. Height: 5’10”. Blood glucose: 125. Exam otherwise unremarkable.

Calculated BMI: 35.1

Assessment: Type 2 diabetes mellitus with CKD stage 2, obesity

ICD-10-CM coding:

E11.22 Type II diabetes mellitus with diabetic chronic kidney disease

N18.2 Chronic kidney disease, stage 2 (mild)

E66.09 Other obesity due to excess calories

Z68.35 Body mass index (BMI) 35.0-35.9, adult

Z79.4 Long term (current) use of insulin

In this case, documentation shows a type 2 diabetic with associated CKD, stage 2. A combination code for the type of diabetes and the complication of CKD requires two codes. The BMI is reported secondary to obesity due to excess calories. The final code identifies current use of insulin as the diabetes control method.


Peggy Stilley, CPC, CPB, CPMA, COBGC, is AAPC director of ICD-10 development and training.

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