Pediatric Coding Alert

Question: Our provider saw a patient whose appointment was scheduled to discuss the patient not having had a bowel movement in five days. During the visit, our pediatrician discovered and diagnosed an ear infection in the patient’s right ear. The ear infection received a definitive diagnosis of H66.41 (Suppurative otitis media, unspecified, right ear) and the pediatrician prescribed antibiotics. They listed R19.4 (Change in bowel habit) to account for the five days without a bowel movement. Which diagnosis should I list first on the claim?

Utah Subscriber

Answer: You don’t mention whether your provider provided any counsel or treatment for the change in bowel movements, but ICD-10-CM guideline IV.G tells you to “list first the ICD-10-CM code for the diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible for the services provided.” The guideline also says, “in some cases, the first-listed diagnosis may be a symptom when a diagnosis has not been established (confirmed) by the provider.” ICD-10-CM guidelines note that the first-listed code is also known as the principal diagnosis.

Following this guideline for this encounter means coding R19.4 (Change in bowel habit) as your first-listed (or principal) diagnosis. The code H66.41 (Suppurative otitis media, unspecified, right ear) and its diagnosis would be listed second for any payer following ICD-10 sequencing guidelines, even though the diagnosis is definitive and the pediatrician prescribed antibiotics as treatment.

Rachel Dorrell, MA, MS, CPC-A, CPPM, Development Editor, AAPC