Determine Sinuses Affected Before Assigning Dx in This Recurrent Sinusitis Encounter
Question: A patient came to our office complaining of headaches, facial pain, and nasal congestion lasting for almost four weeks. Our otolaryngologist diagnosed the patient with acute recurrent sinusitis. Do I code this with J01.80, J01.81, or J01.91? Washington Subscriber Answer: As your otolaryngologist documented the sinusitis was recurrent, you cannot use J01.80 (Other acute sinusitis), as the word “recurrent” does not appear in the code descriptor. However, you may not be able to use J01.81 (Other acute recurrent sinusitis) as the code descriptor specifies that more than one sinus — but not all (pansinusitis) — is infected or inflamed, since the provider didn’t specify how many sinuses are affected. This leaves you with J01.91 (Acute recurrent sinusitis, unspecified), which documents recurrent sinusitis but does not specify the number of sinuses affected. In this case, you should query the provider for additional information on the sinuses involved to enable you to use a more specific code. Remember: You should only assign an unspecified code when neither the diagnostic statement nor the documentation provides enough information to assign a more specific code. This is less specific than codes designated as “other,” which you should use when the diagnosis is specific but does not fit into any of the other categories provided by ICD-10-CM. For example, the other codes in the J01.- (Acute sinusitis) group all specify the sinus affected. For recurrent sinusitis in each one, you would report J01.01 for recurrent sinusitis in the maxillary sinus, J01.11 for recurrent sinusitis in the frontal sinus, J01.21 for recurrent sinusitis in the ethmoidal sinus, J01.31 for recurrent sinusitis in the sphenoidal sinus, and J01.41 for recurrent sinusitis in all sinuses, or pansinusitis. You would use the “other” code, J01.81, if your provider’s documentation indicated two or three sinuses were affected, as you have specific codes for one sinus or all four, but not for two or three. Bruce Pegg, BA, MA, CPC, CFPC, Managing Editor, AAPC
