Z12.31 - Encounter for screening for malignant neoplasm of breast

Clinical Definition

COPD Exacerbation refers to a sudden worsening of COPD symptoms, characterized by increased breathlessness, cough, and sputum production that goes beyond normal day-to-day variations and requires a change in medication.

Documentation Requirements

• Specify acuity:

  • Acute exacerbation

  • Acute on chronic

  • With or without acute lower respiratory infection

• Document severity:

  • Mild

  • Moderate

  • Severe

• Associated conditions:

  • Presence/absence of hypoxia

  • Type of infection if present

  • Current status of baseline COPD

• Treatment provided:

  • Medications administered/prescribed

  • Oxygen requirements

  • Need for hospitalization

Common Synonyms

• "COPD flare-up"

• "Breathing getting worse"

• "COPD acting up"

• "Bad breathing spell"

• "Chest getting tight"

Coding Conflicts

Excludes1:

• Asthma with acute exacerbation

• Decompensated asthma

• Status asthmaticus

Excludes2:

• Acute bronchitis with COPD

• Acute respiratory failure

Scribing.io Automation

The AI scribe automatically identifies:

• Trigger phrases like "worsening COPD" or "COPD exacerbation"

• Measures of severity through vitals and symptoms

• Associated respiratory symptoms

• Treatment changes

• Oxygen saturation values

• Medication adjustments
  The system then generates structured documentation matching ICD-10 requirements while maintaining the narrative flow of the note.