255 In our continuing series aimed at assisting readers with the transition to International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM), this article will discuss documentation elements that support ICD-10-CM code selection for sinusitis. As with many conditions, sinusitis was frequently reported with nonspecific codes when reported with International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM). Code 473.9, unspecified chronic sinusitis, ranked eighth in the American Academy of Pediatrics analysis of the National Ambulatory Medical Care Survey for the years 2008 through 2010. ICD-10-CM codes for sinusitis are not significantly different from ICD-9-CM in that each code set provides for specificity for the condition in acute (J01.-) or chronic (J32.-) occur- rence and the involved sinus (eg, maxillary). One change in ICD-10-CM is the ability to capture recurrence of acute sinusitis. This presents an opportunity to better characterize the nature of the patient presentation and the medical necessity of services provided or referrals for additional workup. Certain combination codes identify the condition and under-lying infection. Sinusitis occurring in influenza should be reported using the combination code for the type of influenza with respiratory manifestations (eg, J11.1, influenza due to unidentified influ- enza virus with other respiratory manifestations). For sinusitis in tuberculosis, see code A15.8, other respiratory tuberculosis. When reporting sinusitis due to other identified infectious agents, codes from categories B95–B97 are reported in addition to codes for sinusitis if known during the encounter. No additional code is indicated to specify purulent and non-purulent sinusitis or sinus perforation because these conditions are referenced to the codes for acute or chronic sinusitis. Note, though, that a diagnosis of allergic sinusitis is reported with a code for allergic rhinitis (J30.-). When acute and chronic sinusitis are diagnosed at the same encounter, codes for each condition are reported. The “excludes2” notes at categories J01 and J32 indicate each category excludes codes for conditions represented by the other but when present, each condition is separately reported. Coding Tip Table 1 provides the documentation elements necessary to support specific code selection for acute or chronic sinusitis. Note that occurrence and type are the key elements of docu- mentation necessary for specific code assignment. A diagnosis of sinusitis without indica- tion of occurrence will default to codes for chronic sinusitis. The type of sinusitis refers to inflamed sinus except in cases of allergic sinusitis or sinusitis in influenza or tuberculosis. Appendix B-14 Documentation of Sinusitis (continued on page 256)
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