Internal Medicine Coding Alert

Question: My internist says that when a pediatric patient presents for the first time with symptoms of asthma, we should not code the condition as asthma. Instead, we should list 519.1 for reactive airway disease and report the appropriate asthma code when the patient presents a second time or after additional tests. Is my physician correct?

Texas Subscriber

Answer: When you use diagnosis codes, you must follow this rule: Code what you see. Therefore, if your internist lists 519.1 (Other diseases of trachea and bronchus, not elsewhere classified) in the patient's record, that's the ICD-9 code you should use. Furthermore, if your internist does not document asthma (493.xx), you cannot report asthma.
 
Suppose your physician documents a patient's condition as "possible," "questionable," "probable," "suspected," or still in the "rule-out phase." In that case, you should not report any diagnosis code, because your physician hasn't listed one as definitive.