ICD 10 Coding Alert

Parentheses, combo codes provide reporting specificity.

Coders are always challenged by ear, nose, and throat (ENT) diagnoses. Even though the anatomical sites are linked, coders have to treat them separately, as it is critical to code selection.

Making matters worse, ICD-10 guidelines add their usual, additional level of complexity that can keep coders scratching their heads.

But if you know your way around the ICD-10 index, you have the tool you need to hone in on the correct codes for this duo of diagnosis coding dilemmas.

Correctly Interpret a Term's Nonessential Modifiers

Diagnosis 1: Traumatic central perforation of right eardrum

Coding this diagnosis can be tricky due to the traumatic specifier. Your first step is to look up Perforation in the ICD-10 index; however, it's at this initial point where codersmay find their first hang-up. Next to Perforation, perforated, you will find the two supplementary words (nontraumatic) (of).

Refresher:  According to ICD-10 guidelines, "Parentheses are used in both the Alphabetic Index and Tabular List to enclose supplementary words that may be present or absent in the statement of a disease or procedure without affecting the code number to which it is assigned."

"These terms in parentheses, known as nonessential modifiers, may be a clue that you are at the right code, whether you are in the index or the tabular section," says Sheri Poe Bernard, CPC, of Poe Bernard Consulting in Salt Lake City, Utah. "But while it may affirm your code choice, don't let a nonessential modifier distract you from using the right code. If the diagnosis you are looking for conflicts with the nonessential modifier, don't worry. After all, it's nonessential. That means it is OK to ignore it," Bernard explains.

The nontraumatic supplementary word could easily dissuade a coder from continuing further down the perforation list of diagnosis codes. However, as long as you have a clear understanding that the supplementary words are not necessarily tied in to the underlying term, you may continue to see what coding options are available under Perforation.

Perforation, perforated (nontraumatic) (of) ⇒ ear drum will lead you to see Perforation, tympanum. Under Perforation, perforated (nontraumatic) (of) ⇒ tympanum, tympanic (membrane) (persistent post-traumatic) (postinflammatory), you have the option of selecting central. However, here is another avenue in which you should not let the supplementary words redirect you. As you can see, one of the supplemental words, persistent post-traumatic, might lead a coder to look elsewhere for a more acute injury code. However, since this descriptor may or may not be present, you should continue under central to find the correct diagnosis code.

Under central, you have the option for multiple or total. Since there is no specification as to whether there are multiple or total perforations of the eardrum, you should opt for the default central perforation of the tympanic membrane code, H72.01 (Central perforation of tympanic membrane, right ear).

Look for Combination Code First

Diagnosis 2: Acute recurrent abscess of the right middle ear resulting in perforation of the central ear drum

While the diagnosis seems like a handful on paper, the actual coding mechanism for this diagnosis is fairly straightforward. The main factor to consider in this situation is whether you will be coding both the abscess and the perforation diagnoses. According to ICD-10 guidelines, "When an admission or encounter is for a procedure aimed at treating the underlying condition (e.g., spinal fusion, kyphoplasty), a code for the underlying condition (e.g., vertebral fracture, spinal stenosis) should be assigned as the principal diagnosis."

With this information at hand, one might assume that the abscess of the ear is the underlying diagnosis, and therefore should be the only diagnosis coded. This would be true unless one of the two following circumstances present themselves:

• The perforation of the eardrum is not definitively linked to the abscess, or
• A combination code exists documenting both the abscess and the perforation.

You will find that, in this example, a combination code does, in fact, exist. Under ear (middle), you will find acute - see Otitis, media, suppurative, acute. Next, you will be lead to recurrent ⇒ with rupture of ear drum ⇒ H66.011 (Acute suppurative otitis media with spontaneous rupture of ear drum, right ear).

In an example such as this, coders should not be quick to assume two separate codes, relays Lindsay Della Vella, COC, medical coding auditor at Precision Healthcare Management in Media, Pennsylvania. "The ICD-10-CM guidelines state that a combination code is a single code used to classify 'two diagnoses or a diagnosis with an associated secondary process or a diagnosis with an associated complication.' The guidelines then go on to state that 'multiple coding should not be used when the classification provides a combination code that clearly identifies all the elements documented in the diagnosis.' So, in this case, H66.011 is correct," Della Vella explains.

Consider: The only additional factor for a coder to consider is the wording of "rupture" versus "perforation." In order to make sure that rupture and perforation are synonymous with each other (in the case of ear drums), simply look up Rupture, ruptured ⇒ ear drum (nontraumatic) which leads you to see also Perforation, tympanum. You may now feel comfortable using code H66.011 to describe an acute recurrent abscess of the right middle ear resulting in perforation of the central ear drum.