The patient was admitted with wheezing and shortness of breath. The provider’s diagnostic statement listed, “Bacterial pneumonia on top of influenza A, exacerbation of chronic obstructive pulmonary disease (COPD).” Would a combination code be assigned for the influenza with pneumonia and COPD and pneumonia; or should each condition be coded separately? Does the fact that a combination code is assigned for COPD with acute lower respiratory infection affect assigning an additional code for influenza with pneumonia? How would this case be coded?
Assign code J10.08, Influenza due to other identified influenza virus with other specified pneumonia; code J44.0, Chronic obstructive pulmonary disease with acute lower respiratory infection; code J15.9, Unspecified bacterial pneumonia; and code J44.1, Chronic obstructive pulmonary disease with (acute) exacerbation. All four codes are needed to capture the diagnostic statement. The circumstances of the admission would determine the principal diagnosis.
Please note that effective October 1, 2017, the “use additional code to identify the infection” note at code J44.0, Chronic obstructive pulmonary disease with acute lower respiratory infection, has been revised to “Code also to identify infection.”