Pulmonology Coding Alert

Question: We recently saw a patient who presented with shortness of breath and a cough. The pulmonologist diagnosed him with pulmonary alveolar proteinosis (PAP). How should we report this diagnosis and the symptoms?

Tennessee Subscriber

Answer: Patients with pulmonary alveolar proteinosis, often notated by physicians as “PAP,” find it difficult to take oxygen from the air and exchange carbon dioxide from the blood due to a buildup of proteins and lipids in the patients’ air sacs. When patients present with this condition, they’ll often complain of shortness of breath (R06.02), dyspnea (R06.00), or a cough (R05). You should code these symptoms only if the physician hasn’t yet diagnosed the patient with PAP.

Once the patient is diagnosed with PAP, you need not report the symptoms – you’ll only report the definitive diagnosis code. Although your pulmonologist is likely to document whether the patient has primary or secondary alveolar proteinosis, ICD-10 includes just one code to describe this condition once the physician makes a diagnosis. Therefore, you’ll report J84.01 (Alveolar proteinosis) for both primary or secondary presentations. However, in cases of secondary alveolar proteinosis, you’ll also report the cause, such as a lung infection or inhalations of dust such as aluminum, using the appropriate ICD-10 codes.