Primary Care Coding Alert

Question: An established  patient with a history of asthma who is now taking Albuterol reports to the FP with a barking cough. The physician performs a level-three E/M service, notes a -croupy-sounding cough- and gives a final diagnosis of asthma. In this scenario, which ICD-9 code (or codes) should I report?


Michigan Subscriber

Answer: You should choose a diagnosis code that reflects the patient's asthma and the croupy sounds. ICD-9 does contain a diagnosis code that represents both.

On the claim, you should list the following codes:

- 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: an expanded problem-focused history; an expanded problem-focused examination; and medical decision-making of low complexity) for the E/M

- 493.90 (Asthma, unspecified) linked to 99213 to represent the patient's asthma and croup. (Note: When you look up -croup- in the ICD-9 index, it instructs you to use 493.9x for asthmatic croup).