Primary Care Coding Alert

Question: We had an established patient with prior history of asthma who came into the clinic with wheezing. How do I code for the asthma and the wheeze?

Montana Subscriber

Answer: When a patient who is diagnosed with asthma presents with wheezing, you typically should use the ICD-9 code for an acute exacerbation of asthma (493.x2). Otherwise, you should clarify the diagnosis with the physician.

Using the symptom code for wheezing (786.07) would be unnecessary and inappropriate. Wheezing is a cardinal sign as well as a symptom of asthma. Conditions and  signs or symptoms included in categories 780-796 consist of cases for which no more specific diagnosis can be made even after all facts bearing on the case have been investigated, states ICD-9.