Primary Care Coding Alert

Question: If lab or imaging data do not support a particular diagnosis, should I report the presenting symptom and/or sign? For example, a patient complains of fatigue and shortness of breath. Should I assign the original diagnosis "fatigue" until lab and/or other data confirm a diagnosis of anemia? Or since the family physician (FP) suspects anemia, should I report the disease?

New Jersey Subscriber Answer: ICD-9 coding guidelines specifically disallow reporting unconfirmed diagnoses. Do not code diagnoses documented as "probable," "suspected," "questionable," "rule out," or "working diagnosis," according to ICD-9's basic coding guidelines for outpatient services. Rather, you should "code the condition(s) to the highest level of specificity for that encounter/visit, such as symptoms, signs, abnormal test results, or other reason for the visit." Therefore, without confirmed laboratory results, you should report the patient's presenting sign and/or symptom.
 
For instance, suppose in the suspected anemia example, the FP performs an expanded problem-focused history, expanded problem-focused examination and
low- complexity medical decision-making. He also orders a complete blood count (CBC) for the patient.
 
Until the lab results confirm that the patient has anemia (such as 285.9, Other and unspecified anemias; anemia, unspecified), you should report the signs and symptoms for the visit - shortness of breath (786.05, Symptoms involving respiratory system and other chest symptoms; shortness of breath) and fatigue (780.79, General symptoms; malaise and fatigue; other malaise and fatigue). Link 786.05 to the office visit (99213, Office or other outpatient visit for the evaluation and management of an established patient ...). Use 780.79 as the reason for the CBC (85025, Blood count; complete [CBC], automated [Hgb, Hct, RBC, WBC and platelet count] and automated differential WBC count; or 85027 ...; complete [CBC], automated [Hgb, Hct, RBC, WBC and platelet count]).