Coding case study: COPD

In the medical billing and coding field, getting paid requires accurate documentation and selecting the correct codes. In our Coding Case Studies, we will explore the correct coding for a specific condition based on a hypothetical clinical scenario. This scenario involves a patient presenting with symptoms of chronic obstructive pulmonary disease (COPD); see if you can choose the correct codes.

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, a 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 treated with Medrol Dosepak (methylprednisolone) and azithromycin.

In October, the same issue was treated with Medrol Dosepak and Augmentin (amoxicillin and clavulanate). Wife states that 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 the left upper field. He has rhonchi in the right middle field, the right lower field, the left middle field and the 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

1. 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 in clinic. Lungs improved, but still have expiratory rhonchi and wheezes. Patient reports breathing is easier but still somewhat tight.

Documentation
Coding Requirements

1. With

• acute lower respiratory infection
• acute exacerbation

2. Unspecified

◆
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

Diagnosis code:

J44.0>>Chronic obstructive pulmonary
disease with (acute) lower respiratory infection ◆◆

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

J44.9>>Chronic obstructive pulmonary
disease, unspecified ◆