Documentation and Coding: COPD and Asthma

A quick reference guide to assist with accurate, complete documentation and coding that reflects the true nature of a patient’s current health status at the highest level of specificity. Per ICD-10 official guidelines for reporting and coding “The importance of consistent, complete documentation in the medical record cannot be overemphasized. Without such documentation accurate coding cannot be achieved.” 

Chronic Obstructive Pulmonary Disease (COPD) 

COPD refers to a group of disease that cause airflow blockage and breathing difficulty. There is no cure for COPD, it can be treated.   

Asthma 

Asthma is a chronic respiratory condition which causes airways to be inflamed, narrow and swell. It also produces mucus which makes it difficult to breath. Asthma can't be cured, but its symptoms can be controlled. 

Documentation & Coding Guidance 

Documentation needs to be clear and detailed using the following terms to allow accurate ICD10 code selection  

• Asthma  
  • Classification: 
    • Mild intermittent: Mild symptoms up to two days a week & up to two nights a month 
    • Mild Persistent: Symptoms more than twice a week, but no more than once in a single day 
    • Moderate Persistent: Symptoms once a day & more than one night a week 
    • Severe Persistent: Symptoms throughout the day on most days & frequently at night 
  • uncomplicated, status asthmaticus or acute exacerbation 
  • allergic, atopic, intrinsic, extrinsic, etc. 
• Bronchitis 
  • Acute or chronic 
  • Simple, mucopurulent, emphysematous, etc. 

Coding Tips: 

• Asthma (J45.xxx)  
  • Excludes: asthma w/COPD, chronic obstructive asthma, and chronic asthmatic (obstructive) bronchitis (J44.9) 
• COPD (J44.x)  
  • Includes: chronic obstructive asthma, asthma w/COPD, chronic obstructive bronchitis, chronic bronchitis with emphysema (J44.9) 
  • Excludes: chronic bronchitis NOS (J42), chronic simple and mucopurulent bronchitis (J41-J41.8), and emphysema without chronic bronchitis (J43-J43.9)  

Treatments include:  

Bronchodilators, anti-inflammatory drugs (Corticosteroids), Mucoactive drugs, Antibiotics, Vaccine, Oxygen therapy, Pulmonary rehabilitation, Lung volume reduction surgery, Lung Transplant, and Lifestyle changes 

References: 

• Coding Clinic for ICD-10-CM/PCS, Fourth Quarter 2017: Page 97 
• ICD-10-CM Official Coding Guidelines for Coding and Reporting 
• https://www.mayoclinic.org/diseases-conditions/asthma/