Certified Risk Adjustment Coder (CRC)

Which statement is true regarding coding COPD when a specific type of asthma is documented?

1. The type of asthma is not reported

2. Only the asthma should be reported

3. Both COPD and asthma should be reported

4. Only the COPD is reported

The correct answer is: The type of asthma is not reported

When coding for conditions like Chronic Obstructive Pulmonary Disease (COPD) and asthma, it is essential to understand how these conditions interact in the context of health records. The correct answer allows coders to recognize that when a specific type of asthma is documented alongside COPD, the primary focus generally should be on the chronic condition that poses the greater risk to the patient and has the potential for greater severity. In medical coding, the guidelines often prioritize reporting the most significant health issue affecting the patient, especially when a specific type of one condition is noted. While COPD and asthma can exist concurrently, coders must assess the documented information. If a specific type of asthma is elaborated upon, it suggests that this condition may be more focal to the patient's treatment or evaluation, which can lead to the conclusion that the COPD might be secondary or less critical in that specific instance. Thus, in coding practice, the type of asthma takes precedence in such situations. Consequently, the instruction not to report the type of asthma separately helps maintain clarity in coding and ensures that the documentation reflects the healthcare provider's treatment focus. This approach enhances the accuracy of patient records and supports vital research and health information systems.