Pulmonology Coding Alert

Question: A new patient reported to the pulmonologist complaining of wheezing and shortness of breath (SOB). The pulmonologist performed a level four E/M, and then ordered a spirometry with graphic record (we own the equipment, and the test was performed and interpreted in-house). Encounter notes describe "likely" emphysema, though the spirometry would not be expected to confirm it. How should I handle the diagnosis coding here? Should I wait for a definitive diagnosis before coding this claim? Minnesota Subscriber Answer: The encounter you describe resulted in an inconclusive diagnosis. However, that does not mean you cannot report -- and be paid for -- the pulmonologist's services. Just make sure the documentation supports patient's presenting symptoms. ICD-9-CM coding guidelines (Section I.B.6. and Section IV.E) state, "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." Translation: [...]