Internal Medicine Coding Alert

Question: A new patient reported to the internist complaining of wheezing and shortness of breath (SOB). The internist performed a level-three E/M, and then ordered a spirometry with graphic record (we own the equipment, and the test was performed and interpreted in-house). Encounter notes describe "likely" emphysema, though the spirometry did not confirm it. How should I handle the diagnosis coding here? Should I wait for a definitive diagnosis before coding this claim?

Minnesota Subscriber

Answer: The encounter you describe resulted in an inconclusive diagnosis; however, that does not mean you cannot report -- and be paid for -- the internist's services. Just make sure the documentation supports the claim, and submit it with ICD-9 codes to represent the patient's presenting symptoms.

ICD-9-CM coding guidelines (Section I.B.6. and Section IV.E) state, "Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a related definitive diagnosis has not been established (confirmed) by the provider."

Translation: If the internist does not confirm emphysema, do not consider reporting any emphysema diagnoses. If the patient comes back for further testing that does reveal emphysema, then you can report an emphysema diagnosis.

On the claim, report the following:

• 94010 (Spirometry, including graphic record, total and timed vital capacity, expiratory flow rate measurement[s], with or without maximal voluntary ventilation) for the spirometry

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

• modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) appended to 99203 to show that the spirometry and E/M were separate services

• 786.05 (Shortness of breath) linked to 94010 and 99203 to represent the patient's SOB

• 786.07 (Wheezing) linked to 94010 and 99203 to represent the patient's wheezing.

Benefit: By coding signs and symptoms, you avoid labeling a patient with an unconfirmed diagnosis. Further, it allows you to code for your internist's services even in those instances when she cannot establish a definitive diagnosis. In addition to "likely," these are other words that can indicate that the physician has not formally diagnosed the patient with a condition:

• probable

• suspected

• questionable

• possible

• still to be determined.