AHA Coding Clinic® for ICD-10-CM and ICD-10-PCS - 2017 Issue 1; Ask the Editor
Acute Exacerbation of Chronic Obstructive Pulmonary Disease with Asthma
When a patient with asthma and chronic obstructive pulmonary disease has an acute exacerbation of COPD, is the asthma reported as exacerbated or unspecified? ...
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Article Overview
This article explains how to approach documentation questions when a patient has both asthma and chronic obstructive pulmonary disease during an acute COPD flare. It is relevant to coding and clinical documentation improvement professionals who need to determine whether the asthma is clearly documented as exacerbated or remains unspecified. The article focuses on the need for provider clarification when the record does not clearly support the asthma status.
Why This Topic Matters
Accurate record interpretation affects diagnosis reporting and helps avoid assuming that one respiratory condition automatically changes the status of another. The article highlights the importance of querying for clarification when documentation is incomplete.
What You Will Learn
- How to evaluate documentation when asthma and COPD are both present
- Why provider clarification may be needed in overlapping respiratory conditions
- The importance of clear clinical documentation during acute COPD exacerbations
- How to approach unspecified versus exacerbated status when the record is unclear
Who Should Read This
- Medical coders
- Coding auditors
- Clinical documentation improvement specialists
- Revenue cycle professionals
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