Revenue Cycle Insider

Question: A patient reported to our practice with fever, muscle pain, sore throat, earache, cough, and a runny nose. Our provider documented the patient had probable influenza and otitis media. As the influenza diagnosis was “probable,” should I only code the symptoms — the fever, muscle pain, sore throat, cough, and runny nose — along with the otitis media?

Connecticut Subscriber

Answer: In coding encounters like this, you would normally follow ICD-10-CM guideline IV.H, which tells you not to code diagnoses “documented as ‘probable,’ ‘suspected,’ ‘questionable,’ ‘rule out,’ ‘compatible with,’ ‘consistent with,’ or ‘working diagnosis’ or other similar terms indicating uncertainty” when coding and reporting diagnoses in outpatient settings. That suggests you would not code a probable case of influenza but use the signs and symptoms the patient exhibited at the time of the encounter to document the visit.

However, in cases of influenza, there is another ICD-10-CM guideline that will override IV.H, and that is guideline I.C.10.c. Even though this guideline tells you to “code only confirmed cases of influenza,” it goes on to say that confirmation “does not require documentation of positive laboratory testing specific for avian or other novel influenza A or other identified influenza virus.”

The guideline then explains that coding for cases of influenza recorded by the provider as “‘suspected,’ or ‘possible’ or ‘probable’ avian influenza, or novel influenza, or other identified influenza, then the appropriate influenza code from category J11, Influenza due to unidentified influenza virus, should be assigned. A code from category J09, Influenza due to certain identified influenza viruses, should not be assigned nor should a code from category J10, Influenza due to other identified influenza virus.”

In other words, as the provider has diagnosed the patient with influenza but has not identified the strain of influenza, you’ll assign a code from J11.- (Influenza due to unidentified influenza virus). More specifically, if the provider documents the otitis media is due to the influenza, you can assign J11.83 (Influenza due to unidentified influenza virus with otitis media) to the encounter, using an additional code from H72.- (Perforation of tympanic membrane) for any associated perforated tympanic membrane, per the instructional note accompanying J11.83.

Bruce Pegg, BA, MA, CPC, CFPC, Managing Editor, AAPC