Pulmonology Coding Alert

Question: I am coding for a pulmonologist who made his initial diagnosis for a patient's COPD. I know this diagnosis should be based on several factors, but I'm not sure what information to look for in the documentation. What can you tell me about these factors?

Alabama Subscriber

Answer: Your physician is likely to include these elements in his documentation when he first diagnoses the patient with COPD:

• In the HISTORY: You should include whether or not the patient had a history of cigarette smoking. The vast majorityof COPD patients have a history of smoking cigarettes. The remaining patients have a history of exposure to pollutants, dusts and chemicals, evidence of genetic tendency (such as alpha-1 Antitrypsin) or history of chronically and poorly controlled asthma. • In the 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.
• In the RADIOGRAPHICAL 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 COPD, so include details about these tests results.
• In the PHYSIOLOGICAL workup: Pulmonary function testing (PFT) is the confirmatory test. You cannot make a solid diagnosis of COPD without having PFT in the medical record. Flow-rate limitation on spirometry and air trapping on the lung volumes are the hallmark findings. Reduced diffusion lung capacity for carbon monoxide (DLCO) is in favor of emphysema, while normal DLCO is in favor of chronic bronchitis.• In the 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.

It is not up to the coder/biller to ensure that all of these tests or findings are present in the documentation before assigning a diagnosis, says Carol Pohlig, BSN, RN, CPC, ACS, senior coding and education specialist at the University of Pennsylvani Department of Medicine in Philadelphia. A biller or coder cannot make medical judgements. As long as the physician has rendered his/her documented opinion, that the patient has COPD, the biller/coder may assign COPD on the claim, she adds.