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This scenario involves a patient presenting with symptoms of chronic obstructive pulmonary disease (COPD). See if you can choose the correct codes.
History of Present Illness
Episode onset: over the last week. The problem has been gradually worsening. The cough is nonproductive. Associated symptoms include rhinorrhea, sore throat, shortness of breath and wheezing. Pertinent negatives include no chest pain, chills, fever, headaches or myalgias. Symptoms are aggravated by lying down. Patient has tried a beta-agonist inhaler for the symptoms. The treatment provided no relief. There is no history of pneumonia.
Patient denies any history of lung problems. Had this same issue in September and was treated with Medrol Dosepak (methylprednisolone) and azithromycin.
In October, patient presented with same issue and was prescribed Medrol Dosepak and Augmentin (amoxicillin/clavulanate). Wife states patient has had moderate relief with past treatment but breathing problem has not completely gone away.
Review of Systems
Constitutional: Positive for fatigue. Negative for chills and fever
HENT: Positive for congestion, rhinorrhea and sore throat. Negative for sinus pressure, sinus pain and trouble swallowing
Respiratory: Positive for cough, chest tightness, shortness of breath and wheezing
Cardiovascular: Negative for chest pain and leg swelling
Gastrointestinal: Negative for nausea and vomiting
Musculoskeletal: Negative for arthralgias and myalgias
Neurological: Negative for dizziness, light-headedness and headaches
Psychiatric/Behavioral: Negative for confusion
Constitutional: Patient is oriented to person, place and time.
Head: Normocephalic and atraumatic
Cardiovascular: Normal rate
Pulmonary/Chest: Accessory muscle usage present. He has wheezes in the right upper field and left upper field. He has rhonchi in the right middle field, right lower field, left middle field and left lower field.
Neurological: He is alert and oriented to person, place and time.
Skin: Warm and dry
Psychiatric: He has a normal mood and affect. His behavior is normal.
Assessment and Plan
COPD with acute exacerbation
DuoNeb (ipratropium-albuterol) 0.5 mg-3 mg(2.5 mg base)/3 mL nebulizer solution; 3 mL doxycycline hyclate 100-mg tablet; Deltasone (prednisone) 20-mg tablet
Patient given nebulizer treatment doxycycline hyclate in clinic. Lungs improved but still have expiratory rhonchi and wheezes. Patient reports breathing easier but still somewhat tight
acute lower respiratory infection
Code also type of asthma, if applicable (J45.-)
Use additional code to identify:
exposure to environmental tobacco smoke (Z77.22)
history of tobacco dependence (Z87.891)
occupational exposure to environmental tobacco smoke (Z57.31)
tobacco dependence (F17.-)
tobacco use (Z72.0)
Code also to identify infection
Renee Dowling is a billing and coding consultant with VEI Consulting in Indianapolis, Indianapolis. Send your diagnosis coding questions to email@example.com