ICD 10 Coding Alert

While querying a provider may seem cumbersome, it can be the best way to ensure accuracy.

Although you know your way around a provider chart and around medical records generally, you may be able to take your diagnosis coding to the next level.

Use these tips for boosting your coding accuracy and tying up any loose ends.

Contact Providers for Clarification

Suppose the physician’s dictation specifically states that the patient has chronic maxillary sinusitis, but then the documentation refers to treating acute maxillary sinusitis, leaving the coder to wonder whether the chronic, acute, or acute on chronic codes applies. What should you do?

Solution – Query the Physician: “Show the discrepancy in the documentation to the physician; once the answer is clarified, the physician should amend the chart note with the appropriate information,” says Elizabeth Cifers, MBA, MSW, CHC, CPC, of Elizabeth Cifers Consulting LLC. “If the physician uses a scribe, educating both the physician and scribe is essential in this process,” she adds.

If the chart documentation does not provide the highest level of specificity to assign a diagnosis code correctly, show the provider the options in the ICD-10-CM code book, so they can see the dilemma in selecting the correct code, she suggests. “Many physicians have been documenting the same way since residency and fellowship and do not realize the level of specificity that ICD-10-CM requires. Education concerning the problem is key to correcting and preventing future occurrences.”

Important: Don’t be afraid to speak up when there is a question or discrepancy in the documentation, Cifers advises. “Unless someone informs the physician, he or she may not know there is an issue.”

Confirm Diagnoses

A patient presents with a painful throbbing in their left ear. The otolaryngologist cites that they strongly suspect an ear infection following an ear exam that doesn’t yield any definitive findings. However, the physician offers no concrete documentation supporting an ear infection in the patient’s chart. What should you do?

Solution: In this case, you should only report the signs and symptoms as they appear in the medical record, which in this case include H92.02 (Otalgia, left ear). Unless otherwise specified, the throbbing should be considered a manifestation or conjunction symptom of the pain, and not separately reported. “Suspected diagnoses are never coded, but they will be documented — in particular if your physician is documenting to optimize their E/M level using medical decision making (MDM) for 2021 office and other outpatient services,” says explains Barbara J. Cobuzzi, MBA, CPC, COC, CPC-P, CPC-I, CENTC, CPCO, of CRN Healthcare in Tinton Falls, New Jersey. Cobuzzi explains that’s because the new MDM guidelines specify to give the physician credit for their thought process, which includes all possible problems and diagnoses. Similarly, the physician’s thought process in determining the plan of care should include all alternatives, even those that are decided to not be followed at the time of the encounter, Cobuzzi advises.

If there’s no ambiguity surrounding the ear infection diagnosis in the note, you’d instead code for this clinical scenario with code H66.92 (Otitis media, unspecified, left ear).

Become Familiar With Common Acronyms

The physician examines a maxillofacial computed tomography (CT) scan of a patient who presented with a headache and facial pressure. For the final diagnosis, the otolaryngologist documents “CRS” in the patient’s chart. This term is unfamiliar to the coding team, so what should you do?

Solution: In this case, it sounds like the physician has diagnosed the patient with chronic rhinosinusitis, sometimes notated by physicians as “CRS.”

Once the patient is diagnosed with CRS, you’ll have to resort to reporting two codes indicating rhinitis and sinusitis since no combination code exists. You will report J31.0 (Chronic rhinitis) for the rhinitis and resort to unspecified code J32.9 (Chronic sinusitis, unspecified) unless the chart indicates one or more sinuses affected. The physician can also be queried as to which sinus is involved so that a more specific chronic sinusitis can be coded. The physician should know which sinus(es) are affected from the chronic sinusitis by reviewing the CT scan.

Practice management: You may want to consider a discussion with any otolaryngologist that frequently includes obscure acronyms, or any sort of lingo that might not be easily decipherable by the coding team. Attempting to standardize dictation reports and medical terminology across urologist is a practical and efficient way of streamlining coding and billing practices. However, your team should also get to know the most common acronyms that your otolaryngologists use and keep a running list along with the codes next to the acronyms. “If you keep the codes on your list, make sure you update the codes each year,” advises Cobuzzi. “The acronyms list can apply to diagnoses and procedures performed. In fact, I even keep an acronym cheat sheet on an Excel spreadsheet with one tab for ICD-10 and one tab for CPT^® codes,” Cobuzzi adds.