Internal Medicine Coding Alert

Published on Fri Jan 25, 2008 PDF

Question: An established patient reports to the internist complaining of trouble breathing and frequent coughing; she also says that "It hurts when I breathe." During a level-three E/M service, the internist 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 Subscriber

Answer: You'll append a single diagnosis code to the E/M. Since the internist 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 internist 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.