Documenting COPD & Asthma

Documenting COPD & Asthma

  • 02 Jun 0
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COPD is a condition that is often times incorrectly documented.   COPD can be referred to as an irreversible airway obstruction associated with chronic bronchitis and/or emphysema.  Asthma is defined as a reversible airway obstruction, which means it can be treated to remove the airway obstruction.

If COPD (496) is documented by itself, the coder can justly assign code 496.  Asthma documented by itself would be assigned ICD-9 code 493.90.   However, when COPD (496) and asthma (493.90) are documented together, careful consideration must be given to how it is documented.   For example, documentation such as: COPD/asthma is not specific enough to assign ICD-9 code 493.20 (Chronic Obstructive Asthma).   ICD-9 guidelines state we must be as specific as possible with our documentation and coding.  The guidelines further state that an ICD-9 code from categories 491-493 (chronic bronchitis, emphysema and asthma) are not to be used with ICD-9 code 496 (COPD).  A better way to document the previous example would be either: chronic obstructive asthma (493.20) OR asthma with COPD (493.20).

It is important to document correctly for proper patient care and treatment.   It is also important to document correctly because ICD-9 code 493.20; chronic obstructive asthma or asthma w/ COPD maps to HCC 111.  Asthma unspecified, ICD-9 code 493.90, does not map to an HCC.

Being as specific as possible is always the best course; it leads to better patient care and proper code assignment.