Revenue Cycle Insider

Question: I have a report that lists the diagnosis as viral lower respiratory tract infection. The physician also documented that the patient has a cough.

Should I report J22 and B97.89 for the patient’s diagnoses? Also, do I need to report the cough in addition to the infection, or is that a symptom of the condition?

Kentucky Subscriber

Answer: You’ll assign J22 (Unspecified acute lower respiratory infection) since the patient is experiencing an acute lower respiratory infection. You won’t assign B97.89 (Other viral agents as the cause of diseases classified elsewhere) because it doesn’t add any descriptive clarity for the condition.

Additionally, you won’t add a separate cough code, such as R05.1 (Acute cough), because a cough is a symptom of a respiratory infection.

Mike Shaughnessy, BA, CPC, Development Editor, AAPC