ICD 10 Coding Alert
Query Physician When the Record’s Unclear
Question: We saw a patient who presented because she was concerned that she may have COPD. The physician circled the COPD diagnosis on the superbill, but we don’t see anything about confirmed COPD in the chart. What should we do? Connecticut Subscriber Answer: In this case, you should query the physician, and if they confirm that COPD was not confirmed, then you should report the signs and symptoms. When patients present with suspected COPD, they may only have a cough or shortness of breath. In this case, you should report symptoms as they appear in the medical record, which might include R06.02 (Shortness of breath), R06.2 (Wheezing), and/or R05 (Cough). But if COPD is the definitive diagnosis and stipulated by the provider in the medical record, coding for this situation would require a code from the J44 (Other chronic obstructive pulmonary disease) code category. That means starting your search with J44.9 (Chronic obstructive pulmonary disease, unspecified) and go from there.
ICD 10 Coding Alert
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