AHA Coding Clinic® for ICD-9 - 2007 Issue 3; Clarifications

Coding Chronic Conditions

We need to get clarification on the coding of chronic conditions. One of the quality improvement organizations (QIOs) will not allow the inclusion of chronic obstructive pulmonary disease (COPD) as a secondary diagnosis when it is only mentioned as a history of COPD and no active treatment is documented. Am I correct in stating the presence of a documented history of COPD in the physician’s history and physical on an inpatient record is enough to code COPD as a secondary diagnosis, since this is a chronic condition that always affects the patient’s care and treatment to some extent? ...

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