Coding corner: Coding and documentation for COPD

Did you know?
Approximately 16 million Americans have chronic obstructive pulmonary disease, or COPD.

Here’s an overview of COPD and tips for documenting and coding it appropriately.

About COPD

COPD is a chronic inflammatory lung disease that results in the obstruction of smaller airways within the lungs. Symptoms may be mild at first, beginning with a cough and shortness of breath with exertion. As it progresses, shortness of breath worsens and may be present at rest. Abnormal levels of oxygen and carbon dioxide in the blood may also be found in patients with advanced COPD. Ultimately, progression of the disease leads to chronic respiratory failure.

COPD is a collective term that includes three specific diseases:

• Chronic bronchitis
• Emphysema
• Asthma with chronic obstruction

Emphysema is characterized by the slow progressive destruction of lung tissue, mainly the small air sacs in the lungs known as alveoli. This interferes with outward air flow from the lungs.

Chronic bronchitis mainly causes inflammation of the bronchial tubes, which allows mucus to build up and obstruct the airways. It also causes some constriction and narrowing of the airways. Patients with longstanding asthma may develop chronic obstruction of the airways and chronic inflammation, similar to chronic bronchitis.

Most patients with COPD have a combination of both emphysema and chronic bronchitis features. Emphysema features will be predominant in some patients, while chronic bronchitis features will be predominant in others.

Symptoms of COPD can vary from one patient to the next, but common symptoms are:

• Shortness of breath
• Frequent coughing, with or without mucus production
• Fatigue
• Wheezing
• Tightness in the chest

Stages of COPD

The stages of COPD are based on the forced expiratory volume, or FEV1. This is the maximal amount of air someone can forcefully exhale in one second. It is then converted to a percentage of normal. The lower the FEV1, the more severe the disease.

• Stage I (early or mild) — FEV1 about 80% or more of normal
• Stage II (moderate) — FEV1 between 50% and 80% of normal
• Stage III (Severe) — FEV1 between 30% and 50% of normal
• Stage IV (very severe or end stage) — FEV1 less than 30%, or people with low blood oxygen levels and a Stage III FEV1

Treatments for COPD

• Bronchodilators to open airways — Most come in the form of inhalers. Both short- and long-acting bronchodilators are available.
• Steroids — These reduce inflammation, swelling and mucus production. Less swelling allows more space through which air can travel. Steroids can be inhaled, taken orally or injected.
• Immunization — Centers for Disease Control and Prevention recommends that individuals with COPD get flu and pneumococcal vaccinations to help protect against complications of COPD.
• Oxygen therapy — Because COPD can lower blood oxygen levels, this treatment provides the body the extra oxygen it needs.

Documentation and coding tips

Always document and code COPD to the highest specificity. The term “COPD” is less specific than the individual diseases it includes. If a patient predominantly exhibits features of one specific disease over another, such as emphysema, chronic obstructive asthma or chronic bronchitis, then this should be documented rather than COPD.

Since conditions under the COPD umbrella can be coded in a variety of ways, the final code selection must consider all the specific details of a patient’s condition as documented by the provider.

With the increased specificity in documentation required by ICD-10-CM guidelines, here are some key points to remember:

• Specify the acuity: acute, chronic, intermittent, or chronic with an acute exacerbation
• Describe the severity: mild, moderate or severe
• Document clinical signs and symptoms: coughing, wheezing, sputum production, shortness of breath
• List any history of tobacco use, environmental exposure or occupational exposure
• Note any diagnostics test: ABGs (arterial blood gas test), PFTs (pulmonary function test), chest X-rays
• Document any treatment: oxygen, bronchodilators, steroids, pulmonary rehabilitation

Some examples of COPD codes are given in the chart below:

Sources:

• copdfoundation.com**
• mayoclinic.org**
• 2019 ICD-10-CM Professional for Physicians

**Blue Cross Blue Shield of Michigan doesn’t own or control this website.

None of the information included in this article is intended to be legal advice and, as such, it remains the provider’s responsibility to ensure that all coding and documentation are done in accordance with all applicable state and federal laws and regulations.