Internal Medicine Coding Alert

Question: A couple of months ago, our provider saw a patient and provided a diagnosis of acute chronic obstructive pulmonary disease (COPD) with mild intermittent uncomplicated asthma. This week, the patient returned, and the doctor's note only had a COPD diagnosis. For the first encounter, I used J44.1 and J45.20. Given that the ICD-10 note that accompanies J44.1 says to code also thetype of asthma, if applicable, should I report the same two codes again for the second encounter?

Kansas Subscriber

Answer: Coding J44.1 (Chronic obstructive pulmonary disease with [acute] exacerbation) with J45.20 (Mild intermittent asthma, uncomplicated) for the first patient encounter is appropriate given the doctor's note.

However, the notes for each encounter must stand alone, and you cannot use a diagnosis from a previous encounter to document the current one. As the doctor did not document the patient's asthma in the second encounter, you should only code the COPD for the second encounter.

So, the second time around, you should only code J44.9 (Chronic obstructive pulmonary disease, unspecified), as you do not mention whether your provider offered more information about the condition, including information about the severity of the COPD. Unless your provider documented an acute lower respiratory infection (J44.0) along with the condition or an exacerbation, acute or otherwise, as in the first encounter, you will have to use the unspecified code.

 Additionally, the "Code also" note in the J44 category states, "Code also type of asthma, if applicable (J45.-)." Since the doctor did not reference asthma in his or her note for the second encounter, the asthma was not applicable, so there is no need to report J45.- in conjunction with the second encounter.

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