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Documentation Tip of the Week: COPD

Posted on Wed, Aug 05, 2015
Documentation Tip of the Week: COPD

Our weekly feature of documentation tips for clinicians.

DID YOU KNOW?
COPD is the No. 9 most denied admission diagnosis by the RAC.

COPD is a chronic condition and should not be admitted to the hospital unless one of these issues is present:

  1. Acute Exacerbation
    • Document acute exacerbation of COPD if admission is medically necessary and steroids nd frequent nebulization treatments are required
  2. Acute Respiratory Failure – frequently the actual reason for the admission
    • Document when the clinical criteria are present
      • requires 2 of the following 3:
        • Respiratory Distress – document this in the physical exam
        • PaO2 < 60mmHg (pulse ox <88%) or higher oxygen requirements for COPD patients on oxygen
        • PaCO2 > 50 mmHg with a pH < 7.35 (means acute)

Chronic Respiratory Failure
Commonly missed diagnosis associated with COPD:
  1. Home oxygen >16 hours a day (not just nighttime oxygen)
  2. PaCO2 > 50 when pH isn’t < 7.35 (means chronic)
Remember to document Acute on Chronic when appropriate.

Remember - Hospital documentation can include “possible, probable, likely or suspected“ diagnoses.



Timothy Brundage, MD, is a hospitalist for EmCare at St. Petersburg General Hospital in St. Petersburg, Fla. Dr. Brundage earned his bachelor’s degree in chemistry and molecular biology at the University of Michigan, his medical degree at the Wayne State University School of Medicine and completed his residency in internal medicine at the University of South Florida College of Medicine. Subscribe to Dr. Brundage’s weekly documentation tips or ask him about specific documentation issues by emailing him at DrBrundage@gmail.com.

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