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Question: I’m fairly new to pediatric coding and my practitioner only noted that the patient had a cough in their notes. How should I code this?

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Answer: You will need to query your practitioner on this one. There are six codes you can choose from in this code set, and because the provider’s documentation was lacking, you will definitely need more information. The cough codes are as follows:

• R05.1 (Acute cough)
• R05.2 (Subacute cough)
• R05.3 (Chronic cough)
• R05.4 (Cough syncope)
• R05.8 (Other specified cough)
• R05.9 (Cough, unspecified)

It’s up to the pediatrician to assign the patient’s cough as acute, subacute, or chronic. Code R05.1 is used for a mild, short-lived cough. In the future, if the notes say the patient’s cough is persistent, refractory, or unexplained, all of those are synonyms for chronic cough, which falls under R05.3. Code R05.4 is appropriate when a patient coughs with such force they lose consciousness after a coughing fit. Be sure you avoid using unspecified codes like R05.9 in favor of a code with more specificity whenever possible.

Lindsey Bush, BA, MA, CPC, Production Editor, AAPC