Should You Code Presenting Symptoms Along With Dx?

Posted on 02. Jan, 2009 by Editor in Coding Challenge

Question: An established patient complains of trouble breathing and frequent coughing; she also says that “it hurts when I breathe.” During a level-three E/M service, the physician diagnoses obstructive chronic bronchitis without exacerbation, prescribes antibiotics, and sends the patient home. Do you need to code the patient’s presenting symptoms, or just the bronchitis?

Answer: You’ll append a single diagnosis code to the E/M. Since the physician reached a diagnosis during the encounter, there is no need to code for the patient’s presenting symptoms.

On the claim, report the following:

• 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: an expanded problem focused history; an expanded problem focused examination; medical decision making of low complexity …) for the E/M.

• 491.20 (Obstructive chronic bronchitis; without exacerbation) appended to 99213 to represent the patient’s bronchitis.

If the physician had not reached a final diagnosis during the encounter, then you would have appended codes for the patient’s presenting symptoms (786.2, Cough; 786.52, Painful respiration) to 99213.

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Tags: 491.20, 99213, diagnosis coding, E/M, ICD-9 coding, pulmonology, signs and symptoms