Revenue Cycle Insider

Question: I’m relatively new to coding. How should I code the following visit?:

Chief complaint: 42-year-old patient complaining of shortness of breath, chronic cough x 6 months, coughing up green mucous. Review of systems is as follows:

Respiratory: Chronic cough and shortness of breath after coughing. Denies wheezing. Gastrointestinal: Occasional acid reflux, managed with Prilosec PRN. Integumentary: Ongoing issues with hidradenitis suppurativa. Allergic/Immunologic: Denies seasonal allergies. PHYSICAL EXAM Constitutional: NAD. Ambulating normally. ENMT: No lesions on external nose, no sinus tenderness, nares patent, rhinorrhea noted. Lips/Teeth/Gums: No mouth or lip ulcers. Oropharynx: no erythema/exudates, moist mucous membranes. Neck: Supple, trachea midline, no masses. Cervical LAD noted. Thyroid non-tender, no enlargement. Lungs: No dyspnea. No wheezing or rales/crackles. Breath sounds normal, good air movement. Cardiovascular: Normal S1/S2, no murmurs or rubs, RRR. DIAGNOSTICS Chest X-ray: No significant findings noted during recent ER visits.

Assessment and plan of care is as follows:

Chronic cough: 6-month chronic cough with mucusy/phlegmy expectoration, worse lying on left side. Associated shortness of breath after intense coughing episodes. Most likely post-nasal drip. Other possible etiologies: GERD, asthma. Plan: Fluticasone nasal spray 50mcg/actuation - 2 sprays each nostril BID. Cetirizine 10mg capsule - 1 capsule daily by oral route in the evening. Qty 30, Refills 3. Famotidine 20mg tablet - 1 tablet BID by oral route. Qty 30, Refills 0. If allergy tx ineffective, trial 2-3 weeks famotidine for possible GERD etiology. If also ineffective, refer to pulmonology for asthma evaluation.

Hidradenitis Suppurativa: Ongoing wound management issues and previous surgical interventions. Plan: Continue current wound care. Follow up with clinic for further evaluation. Potential PICC line placement to be determined. Gabapentin 300mg capsule - 2 capsules TID. Qty 180, Refills 2.

HEALTHCON Attendee

Answer: According to the panel of experts during the HEALTHCON 2026 E/M Panel: “Real-World Documentation & Coding,” Jaci Kipreos, president of Practice Integrity; Leslie Prellwitz, MBA, CCS, CCS-P, CPMA, director of CPT^® Content Management & Development at the AMA; Raemarie Jimenez, CPC, CDEO, CIC, CPB, CPMA, CPPM, CCS, president of Membership & Content at AAPC; and Samuel Church, MD, MPH, CPC, CRC, FAAFP, core faculty family medicine residency at Northeast Georgia Health System and member of the CPT^® Editorial Panel, you would code the case above using 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 30 minutes must be met or exceeded.).

As far as the cough information, Kipreos stated, “You have to trust the provider. In one area they say it’s a chronic cough, and in another area it says it started six months ago.” She ultimately agreed it should be coded as “chronic” using R05.3 (Chronic cough), and for the ongoing wound management, you will need to also code L73.2 (Hidradenitis suppurativa).

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