Q&A: COPD exacerbation

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.

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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. For example:  

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Note the word “acute” is not listed in parenthesis. In this case the word “acute” is required.

Editor’s note: Laurie L. Prescott, RN, MSN, CCDS, CDIP, AHIMA Approved ICD-10-CM/PCS Trainer, is the CDI Education Director at HCPro in Middleton, Massachusetts. Contact her at lprescott@hcpro.com. For information regarding CDI Boot Camps visit http://hcmarketplace.com/clinical-doc-improvement-boot-camp-1.