Pulmonology Coding Alert

Question: What ICD-9 code should I report when the pulmonologist performs a level-two E/M on a new patient? The medical record indicates that the patient had obstructive sleep apnea caused by COPD with exacerbation.

South Dakota Subscriber

Answer: Using 780.51 (Insomnia with sleep apnea, unspecified) is not appropriate for the scenario you've given. Use 780.51 when the physician cannot (or has not yet been able to) determine the cause of the condition. This is not true in your case because the pulmonologist noted a cause for the condition. You should instead choose 327.23 (Obstructive sleep apnea [adult] [pediatric]).

Note: You should bill 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: an expanded problemfocused history; an expanded problem-focused examination; straightforward medical decision-making) for 327.23. Also, include 491.21 (Obstructive chronic bronchitis with [acute] exacerbation) as a secondary diagnosis to represent the patient's co-existing obstructive sleep apnea.