Question: My doctor saw a male Medicare patient with a 3-day history of cough, wheezing and shortness of breath. He has known COPD. My doctor documented acute exacerbation of COPD as well as “acute exacerbation of severe persistent asthma.” What diagnosis(es) should I report?
New Jersey Subscriber
Answer: You should report two diagnoses. You should report J44.1 (Chronic obstructive pulmonary disease with [acute] exacerbation) to represent the COPD in acute exacerbation. Then you should use the additional code of J45.51 (Severe persistent asthma with [acute] exacerbation). At category J44, the instructional note is present to “Code also type of asthma, if applicable (J45.-).
Reference: Check out the Official Coding Guidelines I.C.10.a.1.