Internal Medicine Coding Alert

Question: A patient complained of fatigue and shortness of breath. We sent blood samples to the lab to determine whether the patient has anemia. Should we assign the original diagnosis of "fatigue" until lab data confirm the anemia diagnosis, or should we report anemia, which we suspect she has?

New Jersey Subscriber

Answer: You should never report an unconfirmed diagnosis, so until the office receives the lab results and the physician confirms whether the patient has anemia (such as 285.9, Other and unspecified anemias; anemia, unspecified), you should report the signs and symptoms for the visit. These may include shortness of breath (786.05, Symptoms involving respiratory system and other chest symptoms; shortness of breath) and fatigue (780.79, General symptoms; malaise and fatigue; other malaise and fatigue).

You should link these diagnoses to the office visit code (99213, Office or other outpatient visit for the evaluation and management of an established patient ...). Because you sent the blood samples to a lab, you can report only an E/M code, not a lab code.

Also, remember that ICD-9 coding guidelines specifically state that you should never code diagnoses that the physician documents as "probable," "suspected," "questionable," "rule out," or "working diagnosis." Rather, you should "code the condition(s) to the highest level of specificity for that encounter/visit, such as symptoms, signs, abnormal test results, or other reason for the visit." Therefore, without confirmed laboratory results, you should report the patient's presenting sign and/or symptom.