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Pulmonology Coding Alert

Look for Keywords to Understand COPD

Published on Sun May 27, 2007

Physicians will base an initial COPD diagnosis on several factors, and the medical record will include extensive information about each factor. Pierre Edde, MD, founder of www.pcsbilling.com in Uniontown, Pa., offers the following items that most COPD documentation will include:
 
HISTORY: Should include whether the patient had a history of cigarette smoking. The vast majority of COPD patients have a history of smoking cigarettes. The remaining patients have a history of exposure to pollutants, dusts and chemicals, or evidence of genetic tendency (such as alpha-1 antitrypsin).
 
SYMPTOMS: Shortness of breath (also known as dyspnea) and cough are the cardinal symptoms. Excessive sputum production, wheezing, and recurrent upper respiratory tract infections (URI) are commonly present.
 
RADIOGRAPHIC WORKUP: The chest x-ray shows hyperinflation with flattening of the diaphragms. The CT of the chest is more sensitive and can correlate more accurately with the severity of emphysema, so include details about these tests results.

PHYSIOLOGICAL WORKUP: Pulmonary function tests (PFT) yield the confirmatory tests. The physician cannot make a solid diagnosis of COPD without having PFTs. Flow-rate limitation on spirometry and air trapping on the lung volumes are the hallmark findings. Reduced diffusion lung capacity for carbon monoxide (DLCO) documents the presence of emphysema, while a normal DLCO is found with chronic bronchitis.
 
BLOOD WORK: There are no specific findings until the advanced stage of the disease. Arterial blood gases (ABG) will show evidence of respiratory failure. In emphysema, hypoxemia is more pronounced, while in chronic bronchitis, hypercapnea (CO2 retention) is more evident.
 
Chronic hypoxemia can result in erythrocytosis (elevated hemoglobin and hematocrit) on the complete blood count (CBC), while CO2 retention will lead to elevation of serum bicarbonate (HCO3-) on the electrolytes. Your physician should consider all of these elements, and store the corresponding details somewhere in the medical record to justify his diagnosis of COPD.

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