Revenue Cycle Insider

Hint: Sometimes a clinician’s judgement provides as much confirmation as a test result.

It’s winter virus season again, and regardless of your provider’s specialty, you may encounter patients who are battling a virus. As a coder, it’s important to know how to code a patient’s winter virus experience correctly.  

Read these FAQs and find out the information you need to know to code winter viruses with confidence.

Lean on Clinician Judgement for Flu Dx

Question: Do I need to wait for a clinician to get test results back to confirm — and code — influenza?

Answer: Most coders are very familiar with ICD-10-CM guideline IV.H, which instructs coders not to “code diagnoses documented as ‘probable,’ ‘suspected,’ ‘questionable,’ ‘rule out,’ ‘compatible with,’ ‘consistent with,’ or ‘working diagnosis’ or other similar terms indicating uncertainty” in outpatient settings.

However, coders reporting flu should follow Guideline I.C.10.c, which instructs coders to “code only confirmed cases of influenza …” but with the caveat that confirmation “does not require documentation of positive laboratory testing specific for avian or other novel influenza A or other identified influenza virus.”

This guideline instructs coders to really lean on the provider’s experience and judgement in their diagnosis process: “Coding should be based on the provider’s diagnostic statement” for J09.- (Influenza due to certain identified influenza viruses) if your provider documents that “the patient has avian influenza, or other novel influenza A,” or J10.- (Influenza due to other identified influenza virus) if the patient “has another particular identified strain of influenza, such as H1N1 or H3N2, but not identified as novel or variant.” If the respective patient has a different type of influenza recorded by the provider as “‘suspected,’ ‘possible,’ or ‘probable,’ avian influenza, or novel influenza, or other identified influenza,” ICD-10 guideline I.C.10.c instructs coders to assign an appropriate influenza code from category J11 (Influenza due to unidentified influenza virus).

Refer to Anatomy for This Cold Complication

Question: When a patient has a cold, and a sore throat as well, should I code both conditions?

Answer: When you read the instructions to J00 (Acute nasopharyngitis [common cold]), you’ll see that the code comes with numerous Excludes1 instructions some conditions that manifest alongside the common cold, including:

• J02.- (Acute pharyngitis)
• J02.9 (Acute pharyngitis, unspecified)
• J09.X2 (Influenza due to identified novel influenza A virus with other respiratory manifestations)
• J10.1 (Influenza due to other identified influenza virus with other respiratory manifestations)
• J11.1 (Influenza due to unidentified influenza virus with other respiratory manifestations)
• J31.0 (Chronic rhinitis)

Therefore, if your provider documents both pharyngitis and the cold, you could use the Excludes1 code for the sore throat, presumably a code from the J02.- group, since the throat represents a lower anatomic site than the nasal passages.

Seek Specificity When Reporting a Cough

Question: Can I use R05 to report a patient’s persistent cough?

Answer: The R05 (Cough) code family now has codes with 4^th characters that offer greater specificity for reporting the severity of a cough. Some examples are:

• R05.1 (Acute cough)
• R05.2 (Subacute cough)
• R05.3 (Chronic cough)

When you read the synonyms for R05.3, you’ll see that you can use this code when the physician documents persistent cough, refractory cough (a cough that persists despite treatment), or unexplained cough.

Remember Guidelines Involving Anatomy for Respiratory System

Question: A patient has both nasopharyngitis and chronic pharyngitis. Do I need to report multiple diagnosis codes?

Answer: A note accompanying chapter 10 says “when a respiratory condition is described as occurring in more than one site and is not specifically indexed, it should be classified to the lower anatomic site.”

So if the provider documents both nasopharyngitis and chronic pharyngitis, you would use just one code — J31.2 (Chronic pharyngitis) — on its own, because the pharynx is anatomically lower in the respiratory system than the nasal passages.

Some situations require an additional code, like if the patient is exposed to tobacco smoke or uses nicotine or tobacco. In those situations, you will follow the Use additional code instruction that applies to the entire J00-J99 code section, telling you to use codes such as Z77.22 (Contact with and (suspected) exposure to environmental tobacco smoke (acute) (chronic)), F17.- (Nicotine dependence), or Z72.0 (Tobacco use) for any associated tobacco exposure, dependence, or use.

Report Combination Code Alone

Question: The provider documented the patient as having acute bronchitis, per their signs and symptoms and after a positive swab test for respiratory syncytial virus (RSV). Do I need to report multiple codes for these conditions?

Answer: You can report J20.5 (Acute bronchitis due to respiratory syncytial virus) You don’t need an additional code for the RSV infection because J20.5 is a combination code that includes both the diagnosis and the manifestation.

Use Additional Code for Some Manifestations

Question: A patient develops pneumonia after contracting COVID-19. Do I report U07.1 (COVID-19) and a pneumonia code as well?

Answer: According to Codify by AAPC, you should report U07.1 (COVID-19) as the primary diagnosis, and then an additional code to report the manifestation of pneumonia related to COVID-19. In this case, look to J12.82 (Pneumonia due to coronavirus disease 2019).

Rachel Dorrell, MA, MS, CPC-A, CPPM, Development Editor, AAPC