Wiki COPD and Bronchitis

[Nkeith]

On an EMR record A patient has COPD listed in the PMH. The patient CC is Cough The Physician Assessment is Acute Bronchitis, and Hematuria. In the Exam no mention is made of COPD anywhere but in the PMH. What code would you use for the Diagnosis of Acute Bronchitis in the assessment?

 

[rlh27]

If the patient is taking medication for COPD and that is documented in the medical record, I would ask the provider for clarification.



I would code 466.0 instead of 491.22 if the provider cannot be reached for query.

This is from Coding Clinic:


?All coded diagnoses should be based on the provider's documentation and should meet the definition of a reportable additional diagnosis as outlined in the Official Guidelines for Coding and Reporting.
A condition that does not meet this definition should not be reported. On the other hand, if the patient has been receiving a medication for some time and
continues to receive this treatment during the hospital stay/encounter, it may be appropriate to query the provider for clarification. ?


And this is an article on RAC audits that gives a bit of instruction from HCPRO:

http://www.fortherecordmag.com/archives/051109p00.shtml

They have a more lenient interpretation: "Unless the physician has a direct statement that the past medical condition or the medications the patient is taking for this past medical condition has a direct link on the treatment for the current encounter, coders should not code the past medical history conditions."