Pediatric Coding Alert

Question: I’m looking for some clarity regarding the new ICD-10 guideline that allows us to determine laterality from documentation provided by clinicians other than the treating provider. Does that mean I can go into the patient’s entire record and use relevant information when one of our pediatricians reports an unspecified code?

As an example, a pediatrician saw a patient with chronic allergic otitis media and used the unspecified code, H65.419, for the encounter. However, elsewhere in the patient’s record, I found we had treated the patient several times for the condition, and another pediatrician had documented it as bilateral. Does the guideline mean that I can use the more specific H65.413 for the most recent visit?

AAPC Forum Participant

Answer: Even though a recent change to the ICD-10 guidelines allows you to base diagnosis code assignment for laterality “on medical record documentation from other clinicians” (1.B.13), there are two reasons you cannot assign H65.413 (Chronic allergic otitis media, bilateral) instead of the H65.419 (Chronic allergic otitis media, unspecified ear) that the pediatrician who provided services at the encounter originally assigned.

Why? First, the guideline tells you that “if there is conflicting medical record documentation regarding the affected side, the patient’s attending provider should be queried for clarification.” Simply put, you must defer to the pediatrician attending at the encounter. If, after querying that provider, you cannot document a bilateral code, you must use the code the pediatrician assigned — in this case, the unspecified H65.419.

Second, even though the opening paragraph of the ICD-10 guidelines states “the entire record should be reviewed,” the guideline goes on to specify that this review should be “to determine the specific reason for the encounter and the conditions treated.” In other words, the diagnosis code assigned should be the diagnosis code for the condition at the time of the encounter. So, if the pediatrician cannot be more specific about the condition on the date of service, you will again have to go with the unspecified H65.419 in this scenario.