Pediatric Coding Alert

Question: A patient with abdominal pain came to see our pediatrician. However, during the visit, our pediatrician discovered an ear infection. The ear infection received a definitive diagnosis of H66.41, but the abdominal pain received a symptom code, R10.30, pending test results. In this situation, would the symptom code be used as the primary code even though the other condition has received a definitive diagnosis?

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Answer: ICD-10 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 goes on to say that “in some cases, the first-listed diagnosis may be a symptom when a diagnosis has not been established (confirmed) by the provider.” (Elsewhere in the guidelines, ICD-10 clarifies that the first-listed code is also referred to as the principal diagnosis.)

Following this guideline for this encounter means R10.30 (Lower abdominal pain, unspecified) would be your first-listed or principal diagnosis even though it is not a definitive diagnosis, and even though your provider did not treat the condition pending test results. That means the H66.41 (Suppurative otitis media, unspecified, right ear) diagnosis would be listed second for any payer following ICD-10 sequencing guidelines, even though the diagnosis is definitive, and the condition was the one that ended up being treated.