Q&A: You’ve got questions! We’ve got answers!
Physician Practice Insider, August 23, 2016
Submit your questions to Associate Editor Nicole Votta at nvotta@hcpro.com and we will work with our experts to provide you with the information you need.
Q: Does the provider have to say "acute" exacerbation of COPD or just COPD exacerbation?
A: The best way to figure out the required wording is to take a peek into a code book. If we look at the code J44.1 for COPD exacerbation, you see the word “acute” in parentheses. When words within parentheses are included within the code title, they are referred to as nonessential modifiers, meaning their presence or absence have no impact on the assignment of the code. With this information, we can determine that the word “acute” is not required—if the provider writes “COPD exacerbation” you are able to assign the J44.1 code.
You also see the words “decompensated COPD” and, “decompensated COPD with (acute) exacerbation” listed below the code title. These are described as inclusion terms, and also allow for the assignment of the J44.1 code.
This example does not mean that the word “acute” is always a non-essential modifier.
Editor’s note: Editor’s note: Laurie L. Prescott, RN, MSN, CCDS, CDIP, AHIMA Approved ICD-10-CM/PCS Trainer answered this question for CDI Strategies. Prescott is the CDI Education Director at HCPro in Middleton, Massachusetts. Contact her at lprescott@hcpro.com. This information does not constitute legal advice. Consult legal counsel for answers to specific privacy and security questions. Email your questions to Associate Editor Nicole Votta at nvotta@hcpro.com.
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