Coding case study: Chronic Obstructive Pulmonary Disease

Clinical Scenario

History of Present Illness

Cough

Episode onset: over the last week. The problem has been gradually worsening. The cough is nonproductive. Associated symptoms include rhinorrhea, sore throat, shortness of breath and wheezing. Pertinent negatives include no chest pain, chills, fever, headaches or myalgias. Symptoms are aggravated by lying down. Patient has tried a beta-agonist inhaler for the symptoms. The treatment provided no relief. There is no history of pneumonia.

Patient denies any history of lung problems. Had this same issue in September and was treated with Medrol Dosepak (methylprednisolone) and azithromycin.

In October, patient presented with same issue and was prescribed Medrol Dosepak and Augmentin (amoxicillin/clavulanate). Wife states patient has had moderate relief with past treatment but breathing problem has not completely gone away.

Review of Systems

Constitutional: Positive for fatigue. Negative for chills and fever

HENT: Positive for congestion, rhinorrhea and sore throat. Negative for sinus pressure, sinus pain and trouble swallowing

Respiratory: Positive for cough, chest tightness, shortness of breath and wheezing

Cardiovascular: Negative for chest pain and leg swelling

Gastrointestinal: Negative for nausea and vomiting

Musculoskeletal: Negative for arthralgias and myalgias

Neurological: Negative for dizziness, light-headedness and headaches

Psychiatric/Behavioral: Negative for confusion

Physical Exam

Constitutional: Patient is oriented to person, place and time.

Head: Normocephalic and atraumatic

Cardiovascular: Normal rate

Pulmonary/Chest: Accessory muscle usage present. He has wheezes in the right upper field and left upper field. He has rhonchi in the right middle field, right lower field, left middle field and left lower field.

Neurological: He is alert and oriented to person, place and time.

Skin: Warm and dry

Psychiatric: He has a normal mood and affect. His behavior is normal.

Assessment and Plan

COPD with acute exacerbation

DuoNeb (ipratropium-albuterol) 0.5 mg-3 mg(2.5 mg base)/3 mL nebulizer solution; 3 mL doxycycline hyclate 100-mg tablet; Deltasone (prednisone) 20-mg tablet

Patient given nebulizer treatment doxycycline hyclate in clinic. Lungs improved but still have expiratory rhonchi and wheezes. Patient reports breathing easier but still somewhat tight

Documentation
Coding Requirements

With

acute lower respiratory infection

acute exacerbation

Unspecified

Coding notes

Code also type of asthma, if applicable (J45.-)
Use additional code to identify:

exposure to environmental tobacco smoke (Z77.22)

history of tobacco dependence (Z87.891)

occupational exposure to environmental tobacco smoke (Z57.31)

tobacco dependence (F17.-)

tobacco use (Z72.0)

Code also to identify infection

Renee Dowling is a billing and coding consultant with VEI Consulting in Indianapolis, Indianapolis. Send your diagnosis coding questions to medec@mjhlifesciences.com