Pulmonology Coding Alert

Question: An established patient reports to the pulmonologist complaining of trouble breathing and frequent coughing; she also says that "it hurts when I breathe." During a level-three E/M service, the pulmonologist diagnoses obstructive chronic bronchitis without exacerbation, prescribes antibiotics, and sends the patient home. Do I need to code the patient's presenting symptoms, or just the bronchitis?Ohio SubscriberAnswer: You'll append a single diagnosis code to the E/M. Since the pulmonologist reached a diagnosis during the encounter, there is no need to code for the patient's presenting symptoms.On the claim, report the following:• 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: an expanded problem focused history; an expanded problem focused examination; medical decision making of low complexity ...) for the E/M.• 491.20 (Obstructive chronic bronchitis; without exacerbation) appended to 99213 to represent the patient's bronchitis.If the pulmonologist had not reached a final diagnosis during the encounter, then you would have appended codes for the patient's presenting symptoms (786.2, Cough; 786.52, Painful respiration) to 99213.