Otolaryngology Coding Alert

Question: A patient is seen by the provider for a surgical consult to remove a nasal mass. The patient documents a migraine and a localized pain in the area of the frontal sinus. The location of the mass is not specified. Should I code both the mass and the headache since it's not clear that the migraine is the result of the mass?

Utah Subscriber

Answer: In most scenarios, if the migraine and the mass in question are not definitively linked, you may consider coding both diagnoses, with the mass as the primary diagnosis. However, since you know that this patient is being seen to discuss removal of the nasal mass, you should not consider the migraine to be a secondary diagnosis.

Since the physician did not detail the location of the mass, your diagnostic coding options are somewhat limited. In this case, however, you will rely on the same code whether or not the physician documents the mass as within the frontal sinus or, simply, the nasal cavity. Due to the lack of specificity of both location and the behavior of the mass, you will opt for the diagnosis code J34.9 (Unspecified disorder of nose and nasal sinuses).