You Be the Coder:
Spot 5 Factors In Physician's Notes When Coding COPD
Published on Sat Mar 12, 2011
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 SubscriberAnswer: 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 [...]
