Otolaryngology Coding Alert

Question: I am working on a chart where the patient presents with shortness of breath and a cough with a suspected diagnosis of bronchitis. Which diagnosis should I report as the principal diagnosis?

Georgia Subscriber

Answer: Since the ICD-10-CM manual instructs you not to report any nondefinitive conditions in the outpatient setting, you know not to include bronchitis as the primary diagnosis.

As for the remaining two diagnoses, you may consider either option appropriate to label as the principal diagnosis. Since both coughing and shortness of breath are symptoms of the provider’s suspected diagnosis of bronchitis, you may report both in any order. However, if the provider documents that one symptom is either substantially more apparent or clearly affecting the patient more than the other, you should report that symptom as the principal diagnosis.