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Chronic obstructive pulmonary disease (COPD) encompasses several conditions which may present differently and require different management. The best practice for reporting COPD is to state the specific nature of the condition.
If asthma is present, report as mild, moderate, or severe, and intermittent or persistent.
Tip
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Clinicians should use all available clinical data to represent a specific ICD-10 diagnosis. The default ICD10 code for COPD, Not Otherwise Specified, is J44.9, Chronic obstructive pulmonary disease, unspecified. Complete and accurate documentation of the disease process allows the correct code to be reported.
62 y/o W/M, 2-week follow-up for COPD and inhaler refills. Presents today with wheezing and shortness of breath, states has been better, but had to walk from parking lot.
Vitals - T - 99.2, BP - 132/89, P 48, O2 - 91 , Ht 6’, Wt 210, BMI – 28.5
PMH – COPD, Legionnaires (1997), BPH, Emphysema
Social – divorce × 2, admits to 2 drinks per day, smoker for 16 years, quit smoking 2010 (32 pack years)
Medications – albuterol sulfate, 1 inhalation 2-4 hours
Diagnosis: COPD/Emphysema
Coded as:
J43.9 – Emphysema, unspecified Z87.891 – History of tobacco dependence
*The sole purpose of the examples is to demonstrate the application of coding guidelines discussed in the materials. Examples do not represent complete documentation of a condition, nor provide any clinical advice. Each patient and medical record is unique, and assignment of codes depends solely on the distinct documentation within an individual record.
Providers must confirm the accuracy of their diagnoses to ensure that diagnosis and coding practices comply with ICD-10-CM Official Guidelines for Coding and Reporting and all applicable legal requirements. Failure to address diagnosis inaccuracies can result in administrative sanctions and potential financial penalties. Accurate coding and submission activities allow us to provide the best benefits and resources possible to our customers.
This guide is informational and not meant to replace the clinician’s judgment when caring for the patient.
Content updated April 2023.