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Pulmonology Coding Alert

READER QUESTIONS:

Coding 'Probable' Dx Will 'Likely' Mean Trouble

Published on Wed Jan 28, 2009

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: If the pulmonologist does not confirm emphysema, do not consider reporting any emphysema diagnoses. If the patient comes back for further testing that does reveal emphysema, then you can report an emphysema diagnosis.

On the claim, report the following:

• 94010 (Spirometry, including graphic record, total and timed vital capacity, expiratory flow rate measurement[s], with or without maximal voluntary ventilation) for the spirometry

• 99204 (Office or other outpatient visit for the evaluation and management of a patient, which requires these 3 key components: a comprehensive history; a comprehensive examination; medical decision making of moderate complexity ...) for the E/M

• 786.05 (Shortness of breath) linked to 94010 and 99204 to represent the patient's SOB

• 786.07 (Wheezing) linked to 94010 and 99204 to represent the patient's wheezing.

Benefit: By coding signs and symptoms, you avoid labeling a patient with an unconfirmed diagnosis. Further, it allows you to code for your pulmonologist's services even in those instances when he cannot establish adefinitive diagnosis. In addition to "likely," these are other words that can indicate that the physician has not formally diagnosed the patient with a condition:

• probable

• suspected

• questionable

• possible

• still to be determined.

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