Otolaryngology Coding Alert

J06.9 will be an easy replacement for 465.9.

Your otolaryngologist might diagnose an upper respiratory tract infection (or upper respiratory infection, URI) when any of the components of the patient’s upper airway become infected.

Possible sites of infection include the sinuses, nasal passages, pharynx, and larynx. URIs are some of the most common causes of doctor visits, with symptoms ranging from runny nose, sore throat, and cough to breathing difficulty and lethargy. Although URIs can happen at any time, they are most common in the fall and winter months (from September until March).

Currently, under ICD-9, you have one diagnosis choice for an acute URI if the physician doesn’t document many details: 465.9 (Acute upper respiratory infections of unspecified site). The diagnosis code includes both acute URI NOS and acute URI. You should include an additional code to identify the infectious organism, if known.

Example: The infectious organism is often not known at the initial visit since it often requires a culture to determine the specific organism.  A culture may be taken, for example a nasal culture and it may come back as staphylococcus aureus.  As such, the diagnosis for staphylococcus aureus would be added with the URI diagnosis at the subsequent visit.  (041.11 Methicillin susceptible staphylococcus aureus in conditions classified elsewhere and of unspecified site)

Note: Do not report 465.9 for pneumonia or influenza. Instead, submit a more detailed diagnosis such as 487.0 (Pneumonia; with influenza, flu, or grippe) or 487.1 (Influenza; bronchial).

Stick With a Single Code, Starting October 2014

You’ll still have only one diagnosis code for unspecified acute URI when ICD-10 is introduced in October 2014: J06.9 (Acute upper respiratory infection, unspecified).

You’ll find J06.9 in Chapter 10, Diseases of the Respiratory System; under the subsection Acute Upper Respiratory Infections (J00-J06). As with ICD-9, ICD-10 guidelines state that J06.9 will include acute upper respiratory disease and upper respiratory infection NOS.  Like ICD-0, the chapter guidelines for ICD-10 indicate that the infectious organism should be coded additionally if known.

Documentation: Physicians typically make a diagnosis of upper respiratory infection based on review of symptoms, physical examination, and possibly lab tests. The physician will look for swollen and red nasal cavities, redness of the throat, enlargement of tonsils, white secretions on the tonsils, enlarged lymph nodes around the head and neck, redness of the eyes, and facial tenderness. Other signs might include bad breath (halitosis), cough, hoarseness, or fever.

Because most URIs are caused by viruses, specific testing is not required since there isn’t a specific treatment for different types of viral URIs. If the physician does order lab tests, he could be checking for suspected strep throat, possibly bacterial infection, mononucleosis, or H1N1 flu. Lab tests can also help determine why prolonged symptoms linger.

Keep These Coding Tips in Mind

Coding guidelines for section J06 (Acute upper respiratory infections of multiple and unspecified sites) state that the category does not include diagnoses for acute respiratory infection NOS (J22), influenza virus (J09-J11), or streptococcal pharyngitis (J02.0).

One other code is part of the J06 family in ICD-10: J06.0, which you’ll report for acute laryngopharyngitis. Ensure that you submit J06.0 versus J06.9 correctly, based on your physician’s documentation.

Final tip: Check your provider’s documentation to determine if the patient underwent laboratory testing. If so, don’t assign your final diagnosis codes until you receive lab results.