Pediatric Coding Alert

Hint: No need to code symptoms that are inherent in the final diagnoses.

With just six months left until using ICD-10 codes is mandated, it's a good time to brush up on your diagnosis coding skills. Check out this case study and determine which ICD-10 codes you'd report before reading the solution below.

The case: A 14-year-old established patient presents with severe throat pain that she has been experiencing for three days. In addition, she also has a runny nose, pressure both above and below her eyes, and intermittent headaches. She first noticed the sinus pressure while running with the track team last week, and it grew worse until she had to use warm compresses on her face and forehead last night. No one else in the family is sick and she has no other relevant history.

The diagnosis: The pediatrician examines the patient and diagnoses her with acute tonsillitis and an acute frontal sinus infection.

Coding solutions: Since the pediatrician didn't give information about the cause of the acute tonsillitis and there was no information indicating that it was recurrent, the appropriate code for that diagnosis is J03.90 (Acute tonsillitis, unspecified). You won't separately report any diagnosis codes for the sore throat, since that symptom is inherent in the tonsillitis.

For the sinus infection, you'll report J01.10 (Acute frontal sinusitis, unspecified). You won't report the symptoms that led to this diagnosis, including the facial pain, nasal discharge and pressure.