Wiki Cough and wheeze

[Kreismann]

I would like some help with coding cough with wheezing. Would you add both diagnosis to show the severity? Thank you

 

[blaza192]

I would code both if they are documented. There is no excludes 1, and if there is no definitive diagnosis, all signs and symptoms (R codes) should be coded to accurately represent the patient's status.

 

[Kreismann]

Thank you. Is is also allowed to be coded if the physician did not include the documentation under assessment but documented under physical exam?