Internal Medicine Coding Alert

Question: The internist treats a new patient with a chronic cough and abnormal sputum. During the encounter, the physician performs a comprehensive history and examination and medical decision-making of low complexity. Then, he makes a diagnosis of obstructive chronic bronchitis without acute exacerbation. How many diagnosis codes should I include on the claim?

Idaho Subscriber

Answer: One. Though the patient had specific symptoms (chronic cough, sputum), the internist reached a diagnosis, meaning that the diagnosis coding should reflect the condition, not the symptoms. Report the following:

• 99203 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: a detailed history; a detailed examination; medical decision-making of low complexity) for the E/M.

• 491.20 (Obstructive chronic bronchitis; without exacerbation) linked to 99203 to represent the patient's bronchitis.

Note: If the internist's documentation specifies acute exacerbation, report 491.21 (... with [acute] exacerbation) instead of 491.20.

-- Answers to You Be the Coder and Reader Questions were reviewed by Kathy Pride, CPC, CCS-P, director of government program services for QuadraMed in Reston, Va.; and Bruce Rappoport, MD, CPC, a board-certified internist who works with physicians on compliance, documentation, coding and quality issues for Rachlin, Cohen & Holtz LLP, a Fort Lauderdale, Fla.-based accounting firm with health