Revenue Cycle Insider

Question: I have a report from an encounter with a 57-year-old patient who presented with wheezing. They complained that they could only feel the wheezing on the right side of their body. The pulmonologist performed a flexible bronchoscopy and visualized the vocal cords, trachea, main bronchi, and the segmental bronchi. The provider found a mucus plug obstructing the airway in the bronchus of the right middle lobe. The documentation lists post-obstructive atelectasis under the assessment.

What diagnosis codes will I assign for the encounter?

Maine Subscriber

Answer: Use J98.11 (Atelectasis) for this encounter. During the bronchoscopy, the pulmonologist found a mucus plug obstructing the right middle lobe bronchus. This obstruction blocked the airflow to the alveoli, which resulted in the alveoli collapse. Atelectasis is a condition where a portion of the lung or the entire lung collapses.

The findings in the report show what the physician saw during the procedure, while the assessment is what condition is being caused and why the patient is experiencing their symptoms. You’ll use the assessment in your code selection unless a definitive diagnosis has not been established.

In this case, the patient probably experienced unilateral wheezing due to the alveoli collapse because they were unable to maintain sufficient lung function.

Mike Shaughnessy, BA, CPC, Production Editor, AAPC