Diseases of the Respiratory System
(ICD-10-CM Chapter 10, Codes J00-J99)
Learning Objectives
2. Identify pertinent anatomy and physiology of the respiratory system
3. Identify diseases of the respiratory system
4. Assign the correct Z codes and procedure codes related to the respiratory system
5. Identify common treatments, medications, laboratory values, and diagnostic tests
6. Explain the importance of documentation in relation to MS-DRGs for reimbursement
Abbreviations/Acronyms
AIDS acquired immunodeficiency syndrome
AMI acute myocardial infarction
BIPAP bilevel positive airway pressure
CAP community-acquired pneumonia
COPD chronic obstructive pulmonary disease
CPAP continuous positive airway pressure
E. coli Escherichia coli
GERD gastroesophageal reflux disease
H. flu Haemophilus influenzae
HIV human immunodeficiency virus
ICD-9-CM International Classification of Diseases, 9th Revision, Clinical Modification
ICD-10-CM International Classification of Diseases, 10th Revision, Clinical Modification
ICD-10-PCS International Classification of Diseases, 10th Revision, Procedure Coding System
IPPV intermittent positive pressure ventilation
IV intravenous
LLL left lower lobe
MS-DRG Medicare Severity diagnosis-related group
NEC not elsewhere classifiable
NPPV noninvasive positive pressure ventilation
O2 oxygen
OIG Office of the Inspector General
PaCO2 partial pressure of carbon dioxide in arterial blood
PaO2 partial pressure of oxygen in arterial blood
PCP Pneumocystis carinii pneumonia
RSV respiratory syncytial virus
RUL right upper lobe
STAPH aureus Staphylococcus aureus
TRALI transfusion-related acute lung injury
VATS video-assisted thoracic surgery
ICD-10-CM Official Guidelines for Coding and Reporting
Please refer to the companion Evolve website for the most current guidelines.
10. Chapter 10: Diseases of Respiratory System (J00-J99)
a. Chronic Obstructive Pulmonary Disease [COPD] and Asthma
1) Acute exacerbation of chronic obstructive bronchitis and asthma
The codes in 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, though an exacerbation may be triggered by an infection.
1) Acute respiratory failure as principal diagnosis
A code from subcategory J96.0, Acute respiratory failure, or subcategory J96.2, Acute and chronic respiratory failure, may be assigned as a principal diagnosis when it is the condition established after study to be chiefly responsible for occasioning the admission to the hospital, and the selection is supported by the Alphabetic Index and Tabular List. However, chapter-specific coding guidelines (such as obstetrics, poisoning, HIV, newborn) that provide sequencing direction take precedence.
2) Acute respiratory failure as secondary diagnosis
Respiratory failure may be listed as a secondary diagnosis if it occurs after admission, or if it is present on admission, but does not meet the definition of principal diagnosis.
3) Sequencing of acute respiratory failure and another acute condition
When a patient is admitted with respiratory failure and another acute condition, (e.g., myocardial infarction, cerebrovascular accident, aspiration pneumonia), the principal diagnosis will not be the same in every situation. This applies whether the other acute condition is a respiratory or nonrespiratory condition. Selection of the principal diagnosis will be dependent on the circumstances of admission. If both the respiratory failure and the other acute condition are equally responsible for occasioning the admission to the hospital, and there are no chapter-specific sequencing rules, the guideline regarding two or more diagnoses that equally meet the definition for principal diagnosis (Section II, C.) may be applied in these situations.
If the documentation is not clear as to whether acute respiratory failure and another condition are equally responsible for occasioning the admission, query the provider for clarification.
c. Influenza due to certain identified influenza viruses
Code only confirmed cases of influenza due to certain identified influenza viruses (category J09), and due to other identified influenza virus (category Jl0). This is an exception to the hospital inpatient guideline Section II, H. (Uncertain Diagnosis).
In this context, “confirmation” does not require documentation of positive laboratory testing specific for avian or other novel influenza A or other identified influenza virus. However, coding should be based on the provider’s diagnostic statement that the patient has avian influenza, or other novel influenza A, for category J09, or has another particular identified strain of influenza, such as HlNl or H3N2, but not identified as novel or variant, for category J10.
If the provider records “suspected” or “possible” or “probable” avian influenza, or novel influenza, or other identified influenza, then the appropriate influenza code from category J11, Influenza due to unidentified influenza virus, should be assigned. A code from category J09, Influenza due to certain identified influenza viruses, should not be assigned nor should a code from category J10, Influenza due to other identified influenza virus.
d. Ventilator associated Pneumonia
1) Documentation of Ventilator associated Pneumonia
As with all procedural or postprocedural complications, code assignment is based on the provider’s documentation of the relationship between the condition and the procedure.
Code J95.851, Ventilator associated pneumonia, should be assigned only when the provider has documented ventilator associated pneumonia (VAP). An additional code to identify the organism (e.g., Pseudomonas aeruginosa, code B96.5) should also be assigned. Do not assign an additional code from categories J12-J18 to identify the type of pneumonia.
Code J95.851 should not be assigned for cases where the patient has pneumonia and is on a mechanical ventilator and the provider has not specifically stated that the pneumonia is ventilator-associated pneumonia. If the documentation is unclear as to whether the patient has a pneumonia that is a complication attributable to the mechanical ventilator, query the provider.
2) Ventilator associated Pneumonia Develops after Admission
A patient may be admitted with one type of pneumonia (e.g., code J13, Pneumonia due to Streptococcus pneumonia) and subsequently develop VAP. In this instance, the principal diagnosis would be the appropriate code from categories J12-J18 for the pneumonia diagnosed at the time of admission. Code J95.851, Ventilator associated pneumonia, would be assigned as an additional diagnosis when the provider has also documented the presence of ventilator associated pneumonia.
Apply the General Coding Guidelines as found in Chapter 5 and the Procedural Coding Guidelines as found in Chapters 6 and 7.
Anatomy and Physiology
The primary function of the respiratory system (Figure 16-1) is to supply the body with oxygen (O2). Respiration occurs through the nose and mouth, bringing oxygen through the larynx and trachea and into the lungs, where oxygen is delivered and carbon dioxide is exhaled. Dome-shaped muscles at the bottom of the lungs, or the diaphragm, assist in the process of breathing and in the exchange of oxygen/carbon dioxide. The lungs are the major organ of the respiratory system. The right lung is made up of three lobes; the left lung is smaller and contains two lobes. The bronchi are the two air tubes that branch off the trachea and deliver air to both lungs. The trachea, or windpipe, is responsible for filtering the air that we breathe.
Disease Conditions
Diseases of the Respiratory System, Chapter 10 in the ICD-10-CM code book, are divided into the following categories:
| CATEGORY | SECTION TITLES |
| J00-J06 | Acute upper respiratory infections |
| J09-J18 | Influenza and pneumonia |
| J20-J22 | Other acute lower respiratory infections |
| J30-J39 | Other diseases of upper respiratory tract |
| J40-J47 | Chronic lower respiratory diseases |
| J60-J70 | Lung diseases due to external agents |
| J80-J84 | Other respiratory diseases principally affecting the interstitium |
| J85-J86 | Suppurative and necrotic conditions of the lower respiratory tract |
| J90-J94 | Other diseases of the pleura |
| J95 | Intraoperative and postprocedural complications and disorders of respiratory system, not elsewhere classified |
| J96-J99 | Other diseases of the respiratory system |
In the Respiratory chapter, some codes are provided that do include the organisms. When the organism is included, it is not necessary to assign an additional code for the organism. There will be an Instructional note if it is necessary to use an additional code to identify the infectious agent (Figure 16-2).
This is a combination code that includes the disease process, pneumonia, and the causative organism, respiratory syncytial virus (RSV). No additional code is necessary to identify the organism.
In this case, laryngitis is due to Haemophilus influenzae bacteria (H flu). The code for acute laryngitis, J04.0, makes no mention of the causative bacteria; therefore, code B96.3 is assigned as an additional code to identify the bacteria.
Infection is invasion of the body by organisms that have the potential to cause disease. In the respiratory chapter there are infections and/or inflammations of the upper and lower respiratory tract. It is possible that an acute infection may be superimposed upon a chronic infection or inflammation. Following general guidelines, “If the same condition is described as both acute (subacute) and chronic, and separate subentries exist in the Alphabetic Index at the same indentation level, code both and sequence the acute (subacute) code first” (Figure 16-3).
ICD-10-CM also has some codes to identify an infection that is acute and recurrent. An infection would be classified as recurrent if a patient has had multiple episodes within a year. Recurrent does not necessarily mean the condition is chronic. In a patient with recurrent acute infection a different approach in treating the infection may be necessary. For example, a patient with acute recurrent tonsillitis may require a tonsillectomy. A patient with acute tonsillitis may be treated with antibiotics.
Acute Upper Respiratory Infections (J00-J06) and Other Diseases of Upper Respiratory Tract (J30-J39)
Acute sinusitis occurs when the linings of one or more sinuses become infected, usually because of viruses or bacteria. Sinuses may swell, causing an obstruction and interfering with the normal drainage of mucus. This may occur as the result of a cold. Sinusitis can cause considerable discomfort and may lead to more serious infection.
Chronic sinusitis occurs when the sinuses become inflamed and swollen. Chronic sinusitis may be caused by an infection but could also be due to conditions such as nasal polyps or a deviated nasal septum. It can be difficult to treat and may last 12 weeks or longer.
Exercise 16-1
Assign codes to the following conditions.
| 1. Headache due to acute pansinusitis | _______________ |
| 2. Laryngotracheitis | _______________ |
| 3. Acute streptococcal pharyngitis | _______________ |
| 4. Nasal polyp | _______________ |
| 5. Upper respiratory infection | _______________ |
| 6. Acute and chronic maxillary sinusitis | _______________ |
| 7. Deviated nasal septum | _______________ |
| 8. Paralysis, vocal cords, bilateral | _______________ |
| 9. Allergic rhinitis | _______________ |
| 10. Spasm larynx | _______________ |
Influenza and Pneumonia (J09-J18)
Influenza is a contagious viral infection of the respiratory tract that causes coughing, difficulty breathing, headache, muscle aches, and weakness. Possible complications include pneumonia, encephalitis, bronchitis, and sinus and ear infections. Three types of influenza virus have been identified: Types A, B, and C. Types A and B cause flu epidemics each winter and are the types that may be prevented with a flu shot. Type A is the most common and the most serious type. Influenza C is a very mild respiratory illness that is not thought to be responsible for epidemics.
H1N1 influenza is an influenza virus that is a subtype of influenza A. Because it is a new virus, people may not have any immunity to it. H1N1 influenza poses a greater risk to certain groups of people such as:
Bacterial pneumonia is the most common complication of influenza.
Pneumonia is an infection of the lungs that can be caused by a variety of organisms, including viruses, bacteria, and parasites. Pneumonia frequently follows an upper respiratory infection, and symptoms depend on age and cause of the pneumonia. More than 50 different types of pneumonia have been identified. High-risk individuals include the elderly, the very young, and those with underlying health problems such as chronic obstructive pulmonary disease (COPD), diabetes mellitus, congestive heart failure, asthma, and sickle cell anemia. Those with impaired immune systems as the result of human immunodeficiency virus (HIV) or acquired immunodeficiency syndrome (AIDS), cancer therapy, steroid therapy, or anti-rejection medications are also at risk for developing pneumonia.
Some common symptoms of pneumonia include the following:
Community-acquired pneumonia (CAP) is a broad term that is used to refer to pneumonias that are contracted outside of the hospital or nursing home setting. The most common cause of CAP is Streptococcus pneumoniae. Nosocomial pneumonia refers to a pneumonia that is acquired while the patient is hospitalized. Hospital patients are most susceptible to Gram-negative bacteria and staphylococcal pneumonia. Nursing home–acquired pneumonia refers to a pneumonia that is acquired in a nursing home or extended care facility. More than one organism may be responsible for pneumonia. In this case, pneumonia codes would be assigned to identify both types of pneumonia. If this was the reason for the hospital stay, either could be sequenced as the principal diagnosis. See Table 16-1 for other pathogens responsible for pneumonia. Complications of pneumonia include the formation of abscesses, respiratory failure, bacteremia, pleural effusion, empyema, and pneumothorax.
TABLE 16-1
| Causative Agents | Percentage of All Diagnosed Cases |
| Bacteria | 50 |
| Streptococcus pneumoniae | 10 |
| Haemophilus influenzae | 5 |
| Staphylococcus aureus | 5 |
| Mycobacterium tuberculosis | 10 |
| Viruses | |
| Influenza virus | – |
| Fungi* | |
| Aspergillus fumigatus | – |
| Candida albicans | – |
| Pneumocystis jiroveci | – |
| Bacterium-like organisms | |
| Mycoplasma pneumoniae | 10 |
*Opportunistic infection: rare except in immunosuppressed, debilitated, or terminally ill patients.
A diagnostic workup may be performed to determine the infectious agent that is responsible for the patient’s condition. This could include various cultures, x-rays, and invasive tests, such as bronchoscopy, or a lung biopsy, if necessary. A sputum culture from a healthy person would generally have no growth. A mixture of microorganisms, normally found in or on a patient’s body, may be identified in a culture. This does not necessarily mean that this organism is responsible for a particular infection. A physician may document that a particular organism is a contaminant. This means that the physician does not believe that this organism is responsible for causing the infection. No code would be assigned for an organism that was described as a contaminant. Coders should not assume a causal organism on the basis of laboratory findings alone. All code assignments should be based on the physician’s documentation. A physician query may be necessary to confirm whether the culture findings identify the causative agent or identify a contaminant.
Sometimes, pneumonia may be described as to the lobe that it is located in; for example, right upper lobe (RUL) pneumonia or left lower lobe (LLL) pneumonia. Both of these diagnostic statements are coded to J18.9, pneumonia, unspecified. The location of the pneumonia should not be misinterpreted to mean lobar pneumonia.
Often, empiric treatment (initiation of treatment prior to making a definite diagnosis) with antibiotic will be administered before the organism has been identified or the type of pneumonia determined. For example, patients with HIV may be treated empirically with antibiotics that treat both Pneumocystis carinii pneumonia (PCP) and CAP. Once PCP has been ruled out, the treatment and the type of antibiotic used may be modified. Because Pneumocystis carinii pneumonia was ruled out, it cannot be coded, even though the condition was treated as such until test results were complete.
