Pulmonology Coding Alert

Question: A patient presented to our pulmonology clinic with shortness of breath and a cough that’s persisted for four weeks. The physician diagnosed the patient with pulmonary alveolar proteinosis (PAP).

Should we report the symptoms or the diagnosis?

Colorado Subscriber

Answer: The pulmonologist confirmed a diagnosis of PAP, so you’ll report only J84.01 (Alveolar proteinosis). Your pulmonologist’s documentation may include whether the patient is experiencing primary or secondary alveolar proteinosis, but the ICD-10-CM code set contains just one code to describe the condition. If the patient was diagnosed with secondary alveolar proteinosis, you’d also need to code the cause, such as dust inhalation or a lung infection.

Patients diagnosed with PAP have trouble exchanging oxygen from the air with carbon dioxide in the blood because of an accumulation of proteins and lipids in the lungs’ air sacs. Common symptoms of this condition include R06.02 (Shortness of breath), R06.00 (Dyspnea, unspecified), or R05.- (Cough).

Cough note: ICD-10-CM code R05.- is a parent code that requires a 4th character to specify the patient’s condition. When coding a cough symptom, make sure to check the documentation for a definitive description of the cough, so you can accurately report the symptom. For example, the provider may document how long the patient has been experiencing the symptom, which helps you choose from R05.1 (Acute cough), R05.2 (Subacute cough), and R05.3 (Chronic cough).

An acute cough typically lasts up to three weeks, a subacute cough may persist from three to eight weeks, and a chronic cough lasts longer than eight weeks, but you should base your coding on the provider’s documentation of acute, subacute, or chronic.

Remember: Section I.C.18.a of the ICD-10-CM Official Guidelines instructs you to only code the signs and symptoms when the provider hasn’t confirmed a diagnosis. According to the guideline, “Codes that describe symptoms and signs are acceptable for reporting purposes when a related definitive diagnosis has not been established (confirmed) by the provider.”

In your case, the physician confirmed a PAP diagnosis, so using the applicable code is correct. However, when the physician is unable to confirm a diagnosis, then you assign R06.02 and R05.2 for the patient’s shortness of breath and subacute cough.