Otolaryngology Coding Alert

Take a look at these two P code examples to maximize your ICD-10 coding skills.

Coders are often reluctant to send claims back to the provider for clarification for numerous reasons. Some may simply not want to be a bother, while others incorrectly assume that, if they're forced to send a claim back to the provider, it implies a lack of knowledge or ability on their end.

On the contrary, the most skilled medical coders know that returning claims to the provider for an addendum is simply part of the job. Providers aren't coders, and the occasional documental slip-up is bound to occur. Other times, the documentation may be there, but the diagnosis at hand requires additional information that the provider may not have been aware of. Either way, you should never second-guess whether or not sending a chart back for clarification and/or addendum is the right idea. If you have to ask, it's better to be safe than sorry.

As you'll find with these two examples, sometimes your coding instincts and intuition are enough to know what scenarios do and do not warrant a return to sender claim.

Query Provider for Confirmation of Congenital Disease Transmission

Diagnosis: Newborn hearing loss. Mother diagnosed with toxoplasmosis.

If the provider does not elaborate further on the diagnosis, then this indication needs to be sent back for clarification. First, there is no P code that describes newborn hearing loss. However, the more important consideration comes with the mother's diagnosis of toxoplasmosis. There are two potential scenarios at play:

• The mother passed the toxoplasmosis to the child in utero, in which case the newborn's symptoms are due to congenital toxoplasmosis.
• The mother's toxoplasmosis diagnosis is ultimately coincidental - and unrelated - to the newborn's hearing loss symptoms.

Of the two options, the second sounds less plausible, especially if the mother was diagnosed during the second or third trimester. Depending on the trimester in which the mother was infected, the baby's chances of contracting the disease rise substantially.

In this example, there is no indication by the provider that the newborn's hearing loss is due to congenital toxoplasmosis. "However, when the disease is passed in utero, newborns affected may experience auditory, visual, and motor functioning symptoms - including hearing loss," states Lindsay Della Vella, COC, medical coding auditor at Precision Healthcare Management in Media, Pennsylvania. Therefore, the coder's best course of action is to send this claim back to the provider for further clarification as to the newborn's diagnosis. In most states, newborns are tested for a plethora of diseases, including toxoplasmosis, so the provider should make a follow-up addendum outlining whether or not the newborn's test came back positive.

If the newborn is, in fact, diagnosed with congenital toxoplasmosis, you will exclusively apply code P37.1 (Congenital toxoplasmosis). There is no need to include a code describing the newborn's hearing loss symptoms. However, applying a diagnosis code for an infant with hearing loss without any underlying disease becomes much trickier. Since no hearing loss-specific code exists, you would have to resort to a less specific code to document the newborn's condition. For lack of a better code, you should opt for P96.89 (Other specified conditions originating in the perinatal period).

Know What Circumstances Don't Warrant Addendums

Diagnosis: Newborn nasal discharge, nasal swelling, and fever. Concern for sinus infection.

"Despite the lack of a definitive diagnosis explaining the newborn's symptoms, this diagnosis can be coded as is, without further elaboration by the provider," explains Barry Rosenberg, MD, chief of radiology at United Memorial Medical Center in Batavia, New York. If, for example, there were a test that the provider could perform to definitively diagnose a sinus infection, then you could send the report back in case the provider performs the test after he or she documents these indicating diagnoses. An example where this scenario may apply is if the newborn had symptoms which the provider questioned the possibility of allergies. Assuming the allergy test had been performed on the newborn, you could send the chart back to the provider for an update as to whether allergies are actually the culprit of the newborn's symptoms.

In this example, you will simply code the three underlying symptoms. Due to a lack of a more specific diagnosis for nasal discharge and nasal swelling, you will apply the same P code for both diagnoses: P28.89 (Other specified respiratory conditions of newborn). Asfor the fever, you will apply code P81.9 (Disturbanceof temperature regulation of newborn, unspecified).