ED Coding and Reimbursement Alert

Question: A computed tomography (CT) scan is performed on a patient with a chronic middle ear infection. The indication also notes a positive influenza test result. The provider does not state whether or not the conditions are related. I’d like to report these two conditions separately, but another coder suggests I use a combination code.

Georgia Subscriber

Answer: Despite the fact that the physician doesn’t definitively connect these conditions, you will want to refer to the ICD-10-CM manual to determine your course of action. However, in order to code this properly, you must have a grasp on how to code an ear infection. Infection ⇒ ear (middle) leads you to “see also Otitis media.” But, before you report an otitis media code, you’ll want to look up the patient’s influenza diagnosis first to determine whether a combination code exists.

In the ICD-10-CM index, Influenza (bronchial) (epidemic) (respiratory (upper)) (unidentified influenza virus) ⇒ otitis media leads you to code J11.83 (Influenza due to unidentified influenza virus with otitis media). As you can see via the index, you do not need to determine a cause and effect relationship in order to report code J11.83. When the index uses the term “with,” the accompanying condition only needs to be included as a diagnosis alongside the primary condition.

The same applies for other respiratory manifestations. If, for instance, the provider documents pharyngitis in addition to the influenza diagnosis, but does not state that the pharyngitis is a manifestation of the influenza, you will still report code J11.1 (Influenza due to unidentified influenza virus with other respiratory manifestations). That’s because Influenza ⇒ with pharyngitis leads you to code J11.1. Despite the fact the code description for J11.1 indicates the pharyngitis is a manifestation, you don’t need to prove as much in order to reach the code via the ICD-10-CM index.