Radiology Coding Alert

Question: How should I code a diagnosis of chronic nasal bleeding following sinus surgery?

Florida Subscriber

Answer: As long as the provider clearly documents the epistaxis as a complication of the surgical procedure, you might not consider reporting code R04.0 (Epistaxis) as the primary diagnosis. Since this is a postsurgical complication, your primary ICD-10-CM code should describe as much. In this example, you will use the ICD-10-CM index to find Complication ⇒ postprocedural ⇒ hemorrhage (of) ⇒ respiratory system, which leads you to code J95.830 (Postprocedural hemorrhage of a respiratory system organ or structure following a respiratory system procedure).

However, you should not stop there. Consider the following instructions listed in Section I.C.19.g of the ICD-10-CM guidelines:

• “Intraoperative and postprocedural complication codes are found within the body system chapters with codes specific to the organs and structures of that body system. These codes should be sequenced first, followed by a code(s) for the specific complication, if applicable.”

This means that when applicable, you should code the specific complication as a secondary diagnosis. In this case, you may report R04.0 in addition to J95.830.