Pulmonology Coding Alert

Question: What are the factors that determine an initial diagnosis of COPD?Florida SubscriberAnswer: Physicians will base an initial COPD diagnosis on several factors, and the best documentation will include extensive information about each factor. Most COPD documentation will include:In the HISTORY: Should include whether or not the patient had a history of cigarette smoking. The vast majority of 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 [...]