Pulmonology Coding Alert

Question: Our physician saw a patient who presented with a cough, shortness of breath, fatigue, and phlegm production. The patient stated in the visit they think they have chronic obstructive pulmonary disease (COPD) after searching for their symptoms online. The pulmonologist conducted a spirometry test and chest X-rays but couldn’t confirm a COPD diagnosis.

How should I code the patient’s condition?

Tennessee Subscriber

Answer: You indicated the physician couldn’t confirm a diagnosis of COPD, so your next step is to code the symptoms listed in the documentation. In this case, you’ll assign R05.1 (Acute cough), R06.02 (Shortness of breath), R53.83 (Other fatigue), and R09.3 (Abnormal sputum) to your report.

Why? According to section I.B.4 of the ICD-10-CM guidelines, “Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a related definitive diagnosis has not been established (confirmed) by the provider.” This means that you will code the patient’s symptoms if the provider is unable to establish a diagnosis.