Radiology Coding Alert

Let the ICD-10 guidelines lead you to success when the going gets tough.

No coder is expected to fully memorize the ICD-10 guidelines. With enough coding experience, it's inevitable that you will have to fall back on the ICD-10-CM for guidance from time to time. While most coding scenarios are cut-and-dry, every once in a while, you will encounter a situation that may leave you with more questions than answers.

What many coders don't realize, though, is that the ICD-10 guidelines offer advice on an impressively extensive amount of confounding coding scenarios. Whether it's conflicting diagnoses, ambiguous terminology, or complications following surgery, ICD-10 has you covered on how to properly code the given situation.

Check out these three examples where the ICD-10 guidelines come through in the clutch.

Choose Either Option with 2 Working Diagnoses

Example 1: A patient presents for a maxillofacial computed tomography (CT) scan for restricted airflow from a severe deviated septum and extensive hypertrophy of the inferior turbinates. The physician does not document any conclusive findings in the impression. What are the diagnoses, and which is primary versus secondary?

Making the determination of a primary diagnosis usually boils down to a simple algorithm. If you're able to conclude that one diagnosis is the result of another, then you will have the choice of coding the resulting symptom or diagnosis as either secondary or not at all. In this case, the diagnosis of "restricted airflow" is a common symptom from a deviated septum and hypertrophy of the turbinates. In these cases, the 2018 ICD-10-CM states, "Signs and symptoms that are associated routinely with a disease process should not be assigned as additional codes, unless otherwise instructed by the classification."

Therefore, you can conclude that your primary diagnosis is either J34.2 (Deviated nasal septum) or J34.3 (Hypertrophy of nasal turbinates). However, based on the consultation notes, both seem like suitable candidates for the role of primary diagnosis. In cases like this, you should refer back to the ICD-10-CM guidelines. According to Section II, part C of the ICD-10-CM, "In the unusual instance when two or more diagnoses equally meet the criteria for principal diagnosis as determined by the circumstances of admission, diagnostic workup and/or therapy provided, and the Alphabetic Index, Tabular List, or another coding guidelines does not provide sequencing direction, any one of the diagnoses may be sequenced first."

In other words, ICD-10 is telling you that it's up to your own discretion as to which diagnosis you code as the primary versus secondary. "Since both diagnoses equally meet the criteria for primary diagnosis, either option will work," explains Kimberly Quinlan, CPC, senior medical records coder for the University of Rochester Medical Center's Department of Otolaryngology in Rochester, New York.

If, however, it was noted that the deviated septum was incidental to the patient's symptoms, then you would code the hypertrophy of the turbinates as the primary diagnosis.

Code the Postop Complication Diagnosis First

Example 2: The patient presents for a maxillofacial CT scan with complications following a radiofrequency turbinate procedure of the sinuses. The indication states nasal obstruction, dryness, and pain in the nasal passageway. Despite any conclusive findings, the radiologist states that the symptoms may be a result of empty nose syndrome.

Here, you've got numerous different diagnostic factors. All in all, you've got four diagnoses to consider, three of which being complication symptoms from the surgical procedure. Some might make the false assumption that you should code this visit with the primary diagnosis of J34.3 (Hypertrophy of nasal turbinates), but consider these ICD-10 guidelines on coding complications from surgery.

According to Section II, Part G in the ICD-10-CM, "When the admission is for treatment of a complication resulting from surgery or other medical care, the complication code is sequenced as the principal diagnosis. If the complication is classified to the T80-T88 series and the code lacks the necessary ICD-10-CM Official Guidelines for Coding and Reporting FY 2018 Page 104 of 117 specificity in describing the complication, an additional code for the specific complication should be assigned."

With this information at hand, you can now conclude that you should not use J34.3 as a diagnosis at all, since you have no underlying information that the turbinates are still hypertrophied. Instead, you've got to determine the correct surgical complication code for nasal obstruction, dryness, and pain. Since the nasal passageway is a part of the respiratory tract, you should conclude that J95.89 (Other postprocedural complications and disorders of respiratory system, not elsewhere classified) is the most accurate code available for nasal obstruction and dryness. As for nasal pain, you will apply code G89.18 (Other acute postprocedural pain).

Careful: "The physician's speculation that the patient is experiencing empty nose syndrome is not enough to warrant a diagnosis code," explains Lindsay Della Vella, COC, medical coding auditor at Precision Healthcare Management in Media, Pennsylvania. "However, if the physician definitively concludes that the patient is suffering from empty nose syndrome, you would exclusively apply code J95.89 (Other postprocedural complications and disorders of respiratory system, not elsewhere classified) for lack of a more specific coding option," Della Vella states.

Consider these Guidelines for Either/Or Diagnoses

Example 3: A patient presents for a chest X-ray with complaints of chest pain. In the impression, the radiologist documents a diagnosis of a lung opacity and/or nodule.

Here is another coding scenario in which coders routinely fail to code correctly. Confusion with a set of diagnoses such as these is understandable based on the ambiguity of a definitive diagnosis. While a coder may feel the inclination to send the report back to the provider for clarity, the ICD-10-CM guidelines explain what you should do when this coding scenario arises.

According to Section II, part D, "In those rare instances when two or more contrasting or comparative diagnoses are documented as 'either/or' (or similar terminology), they are coded as if the diagnoses were confirmed and the diagnoses are sequenced according to the circumstances of the admission. If no further determination can be made as to which diagnosis should be principal, either diagnosis may be sequenced first."

Based on this explanation, you can consider the phrasing of "and/or" to be synonymous with "either/or" and therefore make the determination that you should code both diagnoses. Since there is no further elaboration as to the sequencing of the diagnoses, the determination of primary versus secondary diagnosis can be left up to your discretion. You will apply codes R91.1 (Solitary pulmonary nodule) for the nodule and R91.8 (Other nonspecific abnormal finding of lung field) for the opacity, in whichever order you'd like.