Pulmonology Coding Alert

Question: My pulmonologist says that when a pediatric patient presents for the first time with symptoms of asthma, we should not code the condition as asthma. Instead, we should list 519.1 for reactive airway disease, and report the appropriate asthma code when the patient presents a second time or following additional tests. Is my physician correct?

Texas Subscriber

Answer: When you list diagnosis codes, you must follow this rule: Code what you see. Therefore, if your pulmonologist lists 519.1 (Other diseases of trachea and bronchus, not elsewhere classified) in the patient's record, that's the ICD-9 code you should use. Furthermore, if your pulmonologist does not document asthma (493.xx), you cannot report asthma.
 
Suppose your physician documents a patient's condition as "possible," "questionable," "probable," "suspected," or still in the "rule-out phase." In that case, you should not report any diagnosis code, because your physician hasn't listed one as definitive.

 - Answers for You Be the Coder and Reader Questions were reviewed by Carol Pohlig, BSN, RN, CPC, senior coding and education specialist at the University of Pennsylvania department of medicine in Philadelphia; and Anthony M. Marinelli, MD, FCCP, chairman of the American Thoracic Society's Clinical Practice Committee.