Pulmonology Coding Alert

Question: What ICD-9 code should I use for "rule out pulmonary aspiration"? The surgeon did a bronchoscopy, and this is the diagnosis he is billing with. He notes, "This is a 70-year-old man who underwent esophagectomy one week earlier and developed a wound dehiscence, and during his emergency repair, anesthesia department observed gastric contents in the back of his throat." He then describes the procedures.


Michigan Subscriber


Answer: If the physician performed bronchoscopy and confirmed the presence of gastric contents in the airways, you can report 934.x (Foreign body in trachea, bronchus, and lung) on the claim. If the bronchoscopy confirmed that there were no gastric contents in the patient's airways, you can report the "regurgitation" of gastric contents (787.03, Vomiting alone) since this was the indication of the procedure.

You should never report conditions that the physician considers "probable," "possible," "suspected" or "rule out." You should report the signs and/or symptoms that a patient has, until a physician can confirm or rule out the suspected condition (via diagnostic testing or further evaluation).