ICD 10 Coding Alert

Evaluate the note and then select the right codes.

With less than a year before ICD-10 becomes your diagnosis coding reality, it’s time to once again test yourself using a documentation example to determine which ICD-10 codes you would report, then read on for the answers.

Scenario: A six-year-old established patient presents complaining of a sore throat and ear pain. When the pediatrician examines the patient, he finds that she has impacted cerumen bilaterally and therefore cannot visualize her ears. He removes the impacted cerumen with a curette and then finds that the patient has otitis media in the left ear. He performs a rapid strep test with a positive result, and diagnoses the patient with strep throat. Which ICD-10 codes should you report for this visit?

Coding solution: For this patient with strep throat, otitis media and impacted cerumen, you will report the following codes:

Bill the strep throat (J02.0, Streptococcal pharyngitis) and otitis media (H66.92, Otitis media, unspecified, left ear) codes linked to the E/M code (such as 99214, Office or other outpatient visit for the evaluation and management of an established patient…). You’ll also append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) to this office visit code to differentiate it from the impacted cerumen removal procedure.

Report H61.23 (Impacted cerumen, bilateral) linked to the cerumen removal code (69210-50, Removal impacted cerumen requiring instrumentation, unilateral; bilateral procedure). The 50 modifier bilateral demonstrates that the pediatrician performed cerumen removal on both ears.

Tip: You should not report the strep throat diagnosis code unless your practice receives confirmation from a lab test (either rapid strep or throat culture) indicating that the patient tested positive for a streptococcal throat infection. If you don’t have a positive lab test confirming strep throat, you should simply report the diagnosis codes for the symptoms (such as sore throat, fever, etc.).

Therefore, your medical records must document the fact that a laboratory test confirmed that the patient had strep throat before you select your diagnosis code.

In addition, you’ll notice that the otitis media code is now broken down by site—this code refers to the left ear, whereas the right ear would be H66.91 and bilateral ear infections would be reflected by reporting H66.93.

Remember: The unspecified otitis media diagnosis reported in this example could be problematic in ICD-10 and would be better coded with a more specific diagnosis, if known, such as acute suppurative otitis media of the left ear (H66.002)