A hospital inpatient is treated for chronic obstructive pulmonary disease, and the record also documents current tobacco dependence. The Tabular List under the respiratory code includes a “use additional code” note for tobacco use. What should the coder do?
Select an answer to reveal the explanation.
Short Explanation
“Use additional code” is the codebook tapping you on the shoulder: if the chart backs the associated condition—like tobacco with a lung diagnosis—add it. Skipping it because it feels optional is how instructional notes get ignored.
Full Explanation
Instructional notes such as “use additional code” require reporting of an associated condition when documentation supports that condition. For respiratory diseases with tobacco use or dependence documented, an additional tobacco-related code should be assigned per the Tabular instruction and Official Guidelines. The tobacco code supplements the condition being treated; it does not automatically become the principal diagnosis solely because of the note.