Pediatric Coding Alert

Question: In an outpatient physician setting, the pediatrician wrote only "URI vs. Pneumonia" with no symptoms. Should I code both?

Utah Subscriber

Answer: 'Versus' alone is not codeable. Because you can't code one diagnosis versus another, you'll have to ask the physician for either the definitive diagnosis or for the signs/symptoms. Encourage her to mark her own CPT services/procedures and ICD-9 diagnoses. Physician selection has been shown to increase payments, decrease liability, and improve accurate information flow.

For outpatient coding, she would report the definitive diagnosis, such as upper respiratory infection (for in-stance, 465.8, Acute upper respiratory infections of other multiple sites) -- or absent that, the signs or symptoms. For instance, if the physician was waiting for a chest x-ray result, which came back showing viral pneumonia, she would report the definitive diagnosis (480, Viral pneumonia) and not include any listed inherent symptoms.

But if the notes indicate only symptoms and the pediatrician makes no definitive diagnosis, she would code the symptoms accordingly. For instance, she should code a note that reads "cough, difficulty breathing, chest congestion," with 786.2 (Cough), 786.05 (Shortness of breath), and 786.9 (Other symptoms involving respiratory system and chest).