230 Examples Use of an Unspecified Code A child is seen for a sore throat. The strep test result is negative. Diagnosis is acute pharyngitis. In ICD-9-CM, code 462, acute pharyngitis, is reported. In ICD-10-CM, code J02.9, acute pharyngitis, unspecified, is reported. Like ICD-9-CM, ICD-10-CM includes codes for pharyngitis due to certain specified organisms (eg, Streptococcus, Coxsackie virus) that are reported when documented. Query for Information to Assign a Specific Code Documentation indicates that a child is seen for initial evaluation of a superficial foreign body of the thumb with no significant wound and no signs of infection. This documen- tation supports a specific ICD-9-CM code, 915.6, superficial foreign body (splinter) without major open wound and without mention of infection. However, documenta- tion must include laterality for a specific code to be reported in ICD-10-CM. Code S60.369A, initial encounter for super-ficial foreign body of unspecified thumb, may be reported if the thumb is not documented as right or left. However, it would be more appropriate for the coder to query the physician or provider for the additional informa- tion necessary to choose a more specific code including laterality and request that an addendum to the medical record be used to document this (addendum must include current date and be signed by the provider prior to claim submission). Reporting of Signs and Symptoms Documentation for hospital care indicates that a 2-week-old was admitted with a diag- nosis of “rule out sepsis.” Sepsis is ruled out, and discharge diagnoses are fever of unknown origin and poor feeding. ICD-9-CM codes reported for the physician’s services are 778.4, other disturbances of temperature regulation of newborn, and 779.31, feeding problems in newborn. ICD-10-CM codes reported are P81.9, disturbance of temperature regulation of newborn, unspecified, and P92.9, feeding problem of newborn, unspecified. A code for sepsis is not reported because conditions documented with terms such as probable, suspected, or rule out are not reported in conjunction with physician charges. Hopefully, the next year will bring more reassuring information about the adoption of ICD-10-CM. Until then, take note that while ICD-10-CM does require planning and changes in many areas of practice, it does not change everything. Most guidelines are similar to ICD-9-CM, and many physicians already document sufficiently to support the greater specificity of ICD-10-CM diagnoses such as asthma classification and laterality. Appendix B-3 Transitioning to 10: Important ICD-10-CM Clarification: Use of Unspecified Codes (continued from page 229)
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