Primary Care Coding Alert

Know how to code the condition while active, when resolved.

A 59-year-old male patient reports with pain in the cheek and forehead areas; nasal congestion with inflamed nasal passages; thick, colored nasal discharge; and post-nasal drip. The patient reports that he lives with his partner who smokes in the house they share. There is no history of sinusitis.

The provider confirms that the patient has sinusitis, prescribes oral antibiotics, and asks the patient to return in two weeks. The patient does so only to report that the sinusitis has persisted, but the pain is now only located in the cheek areas. This time, the provider documents acute maxillary sinusitis, prescribes a different antibiotic, and asks the patient to return in a month.

When the patient returns, the provider documents that the sinusitis is now resolved.

How would you code these encounters? Read on to see if you agree or disagree with our experts’ analysis of this case study.

Find Your Way Around the J01 Codes

The key to reporting these encounters partly lies in your ability to identify the condition’s timeframe and location.

As with all ICD-10 codes, there is no timeframe specified for the acute and acute recurrent (J01.-) and chronic (J32.-) forms of the condition, so you must rely on your provider’s determination for this.

Thankfully, determining the location of the condition is more straightforward, as ICD-10 identifies four specific sinus locations: maxillary, frontal, ethmoidal, and sphenoidal. You would use the appropriate location whether one or both sides of the patient’s sinuses are affected.

In addition, ICD-10 also identifies three other conditions: pansinusitis, where all the nasal sinuses are affected; “other,” where more than one, but not all, nasal sinuses are affected; and “unspecified,” which you would only use if your provider does not specify which sinuses are affected.

3 Encounters, Many Codes

Coding the E/M for the first visit: “I’d break this visit down as an expanded problem-focused history, an expanded problem-focused exam, and moderate medical decision making [MDM],” says Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians.

“The history would be based on a brief, one-to-three-element history of present illness [HPI]; a one-system problem-pertinent review of systems [ROS]; and a two-element past family and social history [PFSH] that is complete for an established patient but only pertinent for a new patient. The exam touches on two organ systems — constitutional, assuming vital signs were taken, and ears/nose/mouth/throat — which would be an expanded problem-focused exam under the 1995 E/M documentation guidelines or problem-focused under the 1997 guidelines. And the MDM would rise to moderate based on the fact you have an acute new problem without workup [multiple diagnoses and management options] plus moderate risk [prescription drug management],” Moore elaborates.

“This supports a 99202 [Office or other outpatient visit for the evaluation and management of a new patient …] or a 99213 [Office or other outpatient visit for the evaluation and management of an established patient …],” Moore concludes.

Coding the Dx: Here, things get a little tricky. “Since there’s no history of sinusitis, the diagnosis would seem to be acute sinusitis, which is codable to J01.- [Acute sinusitis]. Absent more information, I’d go with J01.9 [Acute sinusitis, unspecified] if using an acute sinusitis code along with an additional code, B95-B97, to identify infectious agent per the note accompanying the J01.- code family.” Moore argues.

However, “any documented ‘sinusitis’ without further specificity is classified as chronic sinusitis in the Alphabetic Index,” Sheri Poe Bernard, CPC, CRC, CDEO, CCS-P, author of the AMA book, Risk Adjustment Documentation and Coding, reminds coders. “This would lead to coding J32.9 [Chronic sinusitis, unspecified] and, per the note that accompanies the chronic sinusitis codes, Z77.22 [… exposure to environmental tobacco smoke …] and the infectious agent if known,” Bernard continues.

Coding caution: “For acuity, quality, and medical necessity reporting, it may be advisable to query the provider for additional information omitted in the encounter being reported,” Bernard notes.

Coding the Second Visit

This time, both of our experts agree that the diagnosis is easier to establish because it is more precise. “In addition to coding this encounter with the appropriate office visit E/M code, which must now be an established patient code since the physician saw the patient two weeks ago, you now have a more specific diagnosis: J01.0- [Acute maxillary sinusitis],” says Moore.

Coding the Third Visit

Again, both experts agree on the coding for this encounter. In addition to the established patient E/M, you would code Z09 (Encounter for follow-up examination after completed treatment for conditions other than malignant neoplasm) as the provider has documented the condition has been resolved. An additional encounter code, Z87.09 (Personal history of other diseases of the respiratory system), would also be appropriate for this situation. “The follow-up code is sequenced first, followed by the history code, per ICD-10 guidelines’” says Bernard.

Coding alert: “Many people would report a sinusitis code in this situation with the argument that until this visit, we don’t know the sinusitis is gone, and therefore the provider is still ‘treating’ it. However, nowhere in ICD-10-CM are resolved respiratory conditions reported as active conditions. Instead, ICD-10 guideline I.C.21.c.8 states, ‘The follow-up codes … imply that the condition has been fully treated and no longer exists,” says Bernard.

“In this case, it may be wise to communicate with payers to ensure whether the use of diagnosis codes for encounters for follow-up of resolved conditions will be accepted or if the payer would prefer an active condition code,” adds Bernard.