ICD 10 Coding Alert

Utilize your problem-solving skills to make sense of the coding process.

The adage about hearing hoofbeats and looking for horses, not zebras, generally applies well to otolaryngology coders. But some zebras certainly exist, and you, as a coder, should feel prepared when outside of your comfort zone and confronting unfamiliar diagnoses.

Use these scenarios to test your knowledge and problem-solving tools for ICD-10 diagnoses.

Look to ICD-10-CM for This Ear Tube Surgery

Diagnosis 1: A child is taken to the operating room (OR) for the removal of a retained ear tube.

This encounter requires further context in order to definitively answer. That’s because your diagnostic coding options will change depending on whether the patient is experiencing complications from the retained tube.

If the encounter is simply to remove the patient’s myringotomy tube, you will report Z45.82 (Encounter for adjustment or removal of myringotomy device (stent) (tube)). If there are complications with the implanted tube, then you should report a complication code in addition to Z45.82.

Have a look at another similar scenario: A child is taken to the OR for the removal of a retained ear tube due to complaints of pain. The surgeon notes an infection at the site of the tube placement.

Here, you’ve got to consider three diagnostic components: the tube removal, the infection, and the pain. The ICD-10-CM guidelines specifically address how to report diagnoses involving pain from devices, implants, or grafts left in a surgical site:

• “Pain associated with devices, implants or grafts left in a surgical site (for example painful hip prosthesis) is assigned to the appropriate code(s) found in Chapter 19, Injury, poisoning, and certain other consequences of external causes. Specific codes for pain due to medical devices are found in the T code section of the ICD-10-CM. Use additional code(s) from category G89 to identify acute or chronic pain due to presence of the device, implant or graft (G89.18 or G89.28).”

This guideline offers the framework of how to report two of your three diagnoses. While the pain is clearly a symptom of the infection, the ICD-10-CM guidelines state that you should report pain using the appropriate G code when it’s the results of a surgical complication. In Chapter 19, you will first report the infection as a complication using code T85.79XA (Infection and inflammatory reaction due to other internal prosthetic devices, implants and grafts, initial encounter). Next, you’ll report acute postprocedural pain code G89.18 (Other acute postprocedural pain) along with Z45.82.

Distinguish Between These Types of Allergic Rhinitis

Diagnosis 2: Allergic rhinitis with fungal debris.

Correctly coding this diagnosis will require you to test your problem-solving skills in addition to your understanding of rhinitis as a condition. In evaluating this diagnosis, you first want to understand that the fungal debris is not a separate diagnosis from the rhinitis, but rather a product of the rhinitis. However, this doesn’t mean that you should not consider it when making your final coding considerations. That’s because the fungal debris reveals that this is a form of allergic fungal rhinitis, and you should code it accordingly.

So, instead of reporting J30.9 (Allergic rhinitis, unspecified) and disregarding the fungal debris as a symptom of the allergic rhinitis, you should be reporting J30.89 (Other allergic rhinitis) for a lack of a more specific code for allergic fungal rhinitis. “There is no code specific to allergic fungal rhinitis, which is not a fungal infection, but an allergic reaction, and reported with J30.89,” says Sheri Poe Bernard, CPC, of Poe Bernard Consulting in Salt Lake City, Utah. “When documentation simply lists ‘fungal debris’ in a patient with allergic fungal sinusitis, it should be considered an incidental finding, and no additional code is needed,” Bernard explains.

“Once the fungal debris has been evaluated by pathology, you will report the appropriate ‘B’ code for the fungus that is present,” says Barbara J. Cobuzzi, MBA, CPC, COC, CPC-P, CPC-I, CENTC, CPCO, AAPC Fellow, of CRN Healthcare in Tinton Falls, New Jersey.

Know These Other Post-Tonsillectomy Bleeding Diagnosis Guidelines

Diagnosis 3: Post-tonsillectomy bleeding.

As long as you know to report this diagnosis as a postsurgical complication, then you should be in the clear. There are numerous ways to find the correct code using the ICD-10-CM index. The most practical is to search the index for Hemorrhage, hemorrhagic (concealed) ⇒ postoperative, which leads you to “see Complications, postprocedural, hemorrhage, by site.” There, you’ll find hemorrhage (of) ⇒ respiratory system ⇒ following procedure on respiratory system organ or structure ⇒ J95.830 (Postprocedural hemorrhage of a respiratory system organ or structure following a respiratory system procedure).

However, as long as you’re fluent with the ICD-10-CM guidelines, you know that there’s at least one more step in the coding process. When possible, you want to add specificity to the claim by reporting the patient’s actual condition as a secondary diagnosis code. Have a look at this guideline in Section C, Chapter 19 of the ICD-10-CM guidelines:

• “Intraoperative and postprocedural complication codes are found within the body system chapters with codes specific to the organs and structures of that body system. These codes should be sequenced first, followed by a code(s) for the specific complication, if applicable.”

Since the ICD-10-CM does not include a more specific diagnosis code for hemorrhage, or bleeding, of the tonsils, then you should not consider this guideline applicable. You should not separately report a nonspecific diagnosis code such as J35.8 (Other chronic diseases of tonsils and adenoids) in its stead.

Your last consideration has to do with the aftercare code. Since the patient is still in the healing and recovery phase of the surgery, this encounter qualifies as an aftercare visit, not a follow up visit. Therefore, you will report Z48.813 (Encounter for surgical aftercare following surgery on the respiratory system) as a secondary diagnosis.

Coder’s note: ICD-10-CM explains that aftercare codes are “generally” first-listed, but this is not a requirement. In the instance that a complication diagnosis is reported in addition to an aftercare visit code, sequence the complication code first, followed by the aftercare visit code.

Refer to Pathology Results for Coding Parapharyngeal Mass

Diagnosis 4: A patient presents for an office visit complaining of swelling in her neck. Using a flexible laryngoscope, the physician identifies a mass in the parapharyngeal space.

For the sake of diagnosis coding purposes, the only information you currently have available to code is a parapharyngeal mass. In a future encounter, the patient may have a biopsy performed (with or without excision), which would allow you to report the mass as either benign or malignant depending on the pathology results. In this example, you will report J39.9 (Disease of upper respiratory tract, unspecified). Since a “mass” is nonspecific, by nature, you should not consider J39.8 (Other specified diseases of upper respiratory tract).

“Industry standards and current ICD-10 guidelines indicate code assignment should be based upon the definitive pathology diagnoses,” explains Ronda Tews, CPC, CHC, CCS-P, AAPC Fellow, director of billing and coding compliance at Modernizing Medicine in Boca Raton, Florida. “The Official Guidelines for Reporting ICD-10-CM indicates that codes titled ‘other’ or ‘unspecified’ should only be used when the information in the medical record is insufficient to assign a more specific diagnosis code or a more specific code does not exist,” relays Tews.