Ambulatory Clinical Documentation

BASICS

 COPD is a general term used to describe a variety of conditions that result in obstruction of the airway.

 COPD has a tremendous effect on the quality of and daily life activities for patients.

 Chronic obstructive bronchitis and emphysema are the two forms of COPD. Asthma is another common chronic

low respiratory disease, but only carries risk through prescription HCCs.

Basics and Beyond

Chronic Obstructive Pulmonary Disease (COPD)

Root Code Detail

J41 Simple and mucopurulent chronic bronchitis (Identify the type)

J42 Unspecified chronic bronchitis

J43 Emphysema (Identify the type)

J44* Other chronic obstructive pulmonary disease

J98 Other respiratory disorders (eg. Disease of the Bronchus)

*J44 includes all of the following: Note: Code also type of asth ma, if applicable (J45.-J45.998)

 Bronchitis as acute or chronic or obstructive, when known

 Severity of COPD (mild, moderate, severe, end-stage)

 Results of pulmonary function tests

 Respiratory failure (acute or chronic) when it occurs as well

as hypoxia or hypercapnia

 If Asthma with COPD (J44.x), include severity (mild,

moderate, severe) type and status

 Dependence on ventilator and any tracheostomy

 Dependence on supplemental oxygen

 Tobacco use, counseling, treatment or intervention

FLIP FOR BEYOND THE BASICS

ICD 10 Code Description Consider Assigning When…

J41.X Chronic Bronchitis Patient has simple and/or mucopurulent chronic br onchitis (Document if

obstructive)

J43.9 Emphysema,

unspecified

When patient has COPD and emphysema throughout. Emphysema is a form of

COPD, so you do not need to code J44.9. If patient also has asthma, code J45.X

based on severity.

J44.9 COPD, unspecified Multiple diagnoses are under the J44.9 umbrella, inc luding chronic obstructive

asthma. Be sure to document severity as either mild, moderate or severe.

J44.0 COPD w/ acute lower

respiratory infection

There is a worsening condition or decompensation. If appropriate, both can be

documented. Also, be sure to include type of infection and infective agent .

Caution: Do not use if infection is caused by influenza, ventilator or in cases of

aspiration pneumonia. In that instance use J44.9 and J95.851.

J44.1 COPD w/ (acute)

exacerbation

Use ALL applicable codes to accurately document a patient’s condition, more than 1 can be documented

Remember to M.E.A.T. (Monitor, Evaluate, Assess and/or Treat) and document:

 Asthma with COPD

 Chronic asthmatic (obstructive)

bronchitis

 Chronic bronchitis with airways

obstruction

 Chronic obstructive asthma

 Chronic bronchitis with emphysema

 Chronic emphysematous bronchitis

 Chronic obstructive

tracheobronchitis

 Chronic obstructive bronchitis

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Download Chronic Obstructive Pulmonary Disease (COPD) and more Study notes Management of Health Service in PDF only on Docsity!

Ambulatory Clinical Documentation

BASICS

 COPD is a general term used to describe a variety of conditions that result in obstruction of the airway.

 COPD has a tremendous effect on the quality of and daily life activities for patients.

 Chronic obstructive bronchitis and emphysema are the two forms of COPD. Asthma is another common chronic

low respiratory disease, but only carries risk through prescription HCCs.

Basics and Beyond

Chronic Obstructive Pulmonary Disease (COPD)

Root Code Detail

J41 Simple and mucopurulent chronic bronchitis (Identify the type)

J42 Unspecified chronic bronchitis

J43 Emphysema (Identify the type)

J44* Other chronic obstructive pulmonary disease

J98 Other respiratory disorders (eg. Disease of the Bronchus)

*J44 includes all of the following: Note: Code also type of asthma, if applicable (J45.-J45.998)  Bronchitis as acute or chronic or obstructive, when known  Severity of COPD (mild, moderate, severe, end-stage)  Results of pulmonary function tests  Respiratory failure (acute or chronic) when it occurs as well as hypoxia or hypercapnia  If Asthma with COPD (J44.x), include severity (mild, moderate, severe) type and status  Dependence on ventilator and any tracheostomy  Dependence on supplemental oxygen  Tobacco use, counseling, treatment or intervention FLIP FOR BEYOND THE BASICS ICD 10 Code Description Consider Assigning When… J41.X Chronic Bronchitis Patient has simple and/or mucopurulent chronic bronchitis (Document if obstructive) J43.9 Emphysema, unspecified When patient has COPD and emphysema throughout. Emphysema is a form of COPD, so you do not need to code J44.9. If patient also has asthma, code J45.X based on severity. J44.9 COPD, unspecified Multiple diagnoses are under the J44.9 umbrella, including chronic obstructive asthma. Be sure to document severity as either mild, moderate or severe. J44.0 COPD w/ acute lower respiratory infection There is a worsening condition or decompensation. If appropriate, both can be documented. Also, be sure to include type of infection and infective agent. Caution: Do not use if infection is caused by influenza, ventilator or in cases of J44.1 COPD w/ (acute) aspiration pneumonia. In that instance use J44.9 and J95.851. exacerbation Use ALL applicable codes to accurately document a patient’s condition, more than 1 can be documented Remember to M.E.A.T. (Monitor, Evaluate, Assess and/or Treat) and document:  Asthma with COPD  Chronic asthmatic (obstructive) bronchitis  Chronic bronchitis with airways obstruction  Chronic obstructive asthma  Chronic bronchitis with emphysema  Chronic emphysematous bronchitis  Chronic obstructive tracheobronchitis  Chronic obstructive bronchitis

Ambulatory Clinical Documentation

Basics and Beyond

Chronic Obstructive Pulmonary Disease (COPD)

BEYOND THE BASICS

ICD10 CODING CONSIDERATIONS MEDICATION AND TREATMENT  Can support diagnosis of COPD, so be sure to document any of the following: ICD10 Code Description Z99.11 Dependence on respirator [ventilator] status Z99.81 Dependence on supplemental oxygen Z79.51 Long term (current) use of inhaled steroids Z79.52 Long term (current) use of systemic steroids

RESPIRATORY FAILURE

 COPD can occur with or without acute or chronic respiratory failure. Document respiratory failure for encounters.  Also consider documentation of hypoxia or hypercapnia in respiratory failure: ICD10 Code Complication J96.01 Acute respiratory failure with hypoxia (oxygen deficient) J96.12 Chronic respiratory failure with hypercapnia (excess carbon dioxide) ICD10 Code Comorbidity J45.X Asthma (including persistence) E66.X Obesity and Overweight, also be sure to document BMI I27.23 Pulmonary HTN due to lung disease and hypoxia code also lung disease J85.1 Abscess of Lung or Pneumonia Example ICD 10 Coding Patient has COPD with acute exacerbation of moderate persistent asthma, O2 dependent, and history of 10 years tobacco dependence.

J44.9, COPD, unspecified AND • J45.41, Moderate Persistent Asthma with (acute) exacerbation AND • Z99.81, Dependence on supplemental oxygen AND • Z87.891, Personal history of nicotine dependence Patient has COPD with emphysema • J43.9, Emphysema, unspecified - Note: There is an exclusion note under J44* (COPD) for emphysema without chronic bronchitis. The code for emphysema includes the COPD, so these should not be added as two separate codes. Patient has COPD and is seen with acute exacerbation of asthmatic bronchitis
J44.1, COPD with (acute) exacerbation AND • J45.901, Unspecified asthma with (acute) exacerbation

ICD10 CODING SCENARIOS

SEVERITY

 When coding for COPD it is important to remember to document diagnosis severity:

COMORBIDITIES

 Or medical conditions that exist at the same time as diagnosis or later develop in conjunction with COPD  Common comorbidities with COPD include: ICD10 Code Description F17.X Nicotine dependence Z72.0 Tobacco Use Z77.22 Contact with and (suspected) exposure to environmental tobacco smoke (acute/ chronic) Z87.891 History of nicotine dependence

RISK FACTORS

 It is important to obtain patient’s smoking status when they have any chronic lung disease  Also, be sure to document tobacco counseling, treatment or intervention Diagnosis Severity Classifications Bronchitis Chronic or Acute COPD Mild, Moderate or Severe Asthma Mild Intermittent, Mild Persistent, Moderate Persistent, Severe Persistent AND Status

Chronic Obstructive Pulmonary Disease (COPD), Study notes of Management of Health Service

Related documents

Partial preview of the text

Download Chronic Obstructive Pulmonary Disease (COPD) and more Study notes Management of Health Service in PDF only on Docsity!

Ambulatory Clinical Documentation

BASICS

 COPD is a general term used to describe a variety of conditions that result in obstruction of the airway.

 COPD has a tremendous effect on the quality of and daily life activities for patients.

 Chronic obstructive bronchitis and emphysema are the two forms of COPD. Asthma is another common chronic

low respiratory disease, but only carries risk through prescription HCCs.

Basics and Beyond

Chronic Obstructive Pulmonary Disease (COPD)

J41 Simple and mucopurulent chronic bronchitis (Identify the type)

J42 Unspecified chronic bronchitis

J43 Emphysema (Identify the type)

J44* Other chronic obstructive pulmonary disease

J98 Other respiratory disorders (eg. Disease of the Bronchus)

Ambulatory Clinical Documentation

Basics and Beyond

Chronic Obstructive Pulmonary Disease (COPD)

BEYOND THE BASICS

RESPIRATORY FAILURE

ICD10 CODING SCENARIOS

SEVERITY

COMORBIDITIES

RISK FACTORS