Otolaryngology Coding Alert

Tip: Watch for comorbidities or other conditions you can report.

Currently, when the otolaryngologist reports a diagnosis of frontal acute sinusitis, you have a single diagnosis choice: 461.1 (Acute sinusitis, frontal). Once ICD-10-CM becomes effective in October 2014, diagnosis 461.1 will map directly to J01.10 (Acute frontal sinusitis, unspecified).

ICD-10-CM change: The only difference in descriptor wording between 461.1 and J01.10 is the addition of the word “unspecified.” The two diagnoses options in ICD-10-CM are J01.10 as described above and J01.11, (Acute frontal sinusitis, unspecified). This simply clarifies that J01.10 is the appropriate diagnosis choice when the physician hasn’t documented whether the sinusitis is recurrent or not, or has documented that this is an initial case.

Documentation: Major signs and symptoms of acute frontal sinusitis include fever, facial pain or pressure, nasal obstruction, or nasal discharge with purulence, and hyposmia/anosmia. Cough, dental pain, headache, and ear pain or ear fullness are considered minor signs and symptoms. Make sure your otolaryngologist include these symptoms in her notes to support the diagnosis choice.

Most practices consider acute frontal sinusitis as a more serious type of acute sinus infection because of its potential complications. The physician might decide to perform frontal sinus surgery to prevent potentially life-threatening complications when the infection fails to respond to conservative therapy (defined as the use of intravenous antibiotics and mucolytic agents along with topical and systemic decongestants for three to five days).

Coding tips: The patient might have comorbidities or other chronic conditions that could affect the treatment (and your coding) for acute frontal sinusitis. For example, the patient might have asthma (J45.2x, Mild intermittent asthma) or emphysema (J43.x) that could complicate treatment. This, as well as medications the patient takes or adverse reactions the patient had to previous medications, could increase the level of your physician’s medical decision making (MDM).

Comorbidities (the need for diagnostic testing), evaluation of symptoms, and the plan of care might also complicate the MDM. If a patient with sinusitis also has these other symptoms, make sure he doesn’t have any other problems that could be more serious. You should find all this information in your physician’s chart.

Description: Acute frontal sinusitis is the inflammation of mucosal lining of frontal sinus which lasts less than three weeks. The condition often is preceded by viral infections of the upper respiratory tract. Early diagnosis and management of acute frontal sinusitis will go a long way in preventing the development of complications.