Apply Your Sinusitis Knowledge to ICD-10-CM and EHRs
Be sure your EHR can handle the detail required for the new sinusitis codes.
by Jaci Johnson, CPC, CPC-H, CPMA, CEMC
Now that electronic health records (EHRs) are commonplace, it’s important to have a good understanding of what they will look like after ICD-10 has been implemented. For example, will the screen that displays the diagnosis options look the same as it does now, perhaps only wider to accommodate the increased verbiage and characters? Or will the EHR allow for a snapshot of what you would see if you were looking at that page in the actual code book?
Consider a diagnosis that often causes problems in ICD-9-CM that may create some of the same problems (and possibly a few new ones) in ICD-10-CM: Sinusitis. ICD-9-CM offers many options, yet the sinusitis code most often selected is 461.9 Acute sinusitis, unspecified. If the documentation was reviewed, would it confirm the coding? Or would documentation provide further information to define the specific location?
Last month, AAPC Cutting Edge briefly touched upon sinusitis in the A&P Quiz and ICD-10-CM Coding Tip on page 22. Let’s expand on what we’ve learned.
WebMD defines sinusitis as “an inflammation, or swelling, of the tissue lining the sinuses. Normally, sinuses are filled with air, but when sinuses become blocked and filled with fluid, germs (bacteria, viruses, and fungi) can grow and cause an infection.” The National Institute of Allergy and Infectious Diseases explains that paranasal sinuses are inflamed due to infection, which causes pain, drainage problems, and mucus build-up. Anyone who has experienced sinusitis can identify with the pain associated with the swelling.
According to Wikipedia, the paranasal sinuses “are a group of four paired air-filled spaces that surround the nasal cavity (maxillary sinuses), above the eyes (frontal sinuses), between the eyes (ethmoid sinuses), and behind the ethmoids (sphenoid sinuses). The sinuses are named for the facial bones in which they are located.” Taber’s Cyclopedic Medical Dictionary further explains, the “Function of the sinuses are not definitely known. Various theories give them the same function as nasal cavities.”
In addition to the patient indicating the location of the pain, the provider often will tap the face around the sinus areas to better determine the location of the swelling. If the location of the affected sinus is determined, documentation and coding should reflect this finding.
Sinusitis is defined by the American Academy of Otolaryngology – Head and Neck Surgery (AOA-HNS) as:
- Acute – lasts less than four weeks
- Subacute – lasts four to 12 weeks
- Chronic – lasts more than 12 weeks, with or without acute exacerbation
- Recurrent acute – four or more acute episodes per year
According to the National Institute of Allergy and Infectious Diseases:
- Acute sinusitis (acute rhinosinusitis) causes the cavities around nasal passages (sinuses) to become inflamed and swollen. This interferes with drainage and causes mucus to build up.
- Acute recurrent sinusitis constitutes several attacks of acute sinusitis within one year, which may lead to chronic sinusitis.
- Chronic sinusitis lasts more than 12 weeks, or keeps coming back.
- Pansinusitis is inflammation of all paranasal cavities, on one or both sides.
- Clinical documentation will need to support one of these definitions.
Code It in ICD-10-CM
ICD-10-CM codes for sinusitis are found in chapter 10, Diseases of the Respiratory System, which includes codes J00-J99. ICD-10-CM instructional notes at the beginning of the chapter tell you to use an additional code (when applicable) to identify:
- Exposure to environmental tobacco smoke
- Exposure to tobacco smoke in the perinatal period
- History of tobacco use
- Occupational exposure to environmental tobacco smoke
- Tobacco dependence
- Tobacco use
Now is a good time to ask your EHR vendors if this information will be available to you when the system upgrades to ICD-10-CM.
Codes for sinusitis are categorized based on whether the documentation indicates an acute or a chronic condition. Codes for acute sinusitis begin with category J01. The fourth character further defines the sinusitis based on the documented sinus(es) involved. A fifth character describes whether the acute condition is recurrent. For example:
J01 Acute sinusitis
J01.0 Acute maxillary sinusitis
J01.00 Acute maxillary sinusitis, unspecified
J01.01 Acute recurrent maxillary sinusitis
In addition to the codes, there are two informational phrases found in the codebook that may be applied to an EHR. First, there is a statement to use an additional code to identify the infectious agent, if known.
There are also two Excludes notes. The Excludes1 note indicates not to use these codes to describe sinusitis, not otherwise specified (NOS), which would be coded as J32.9 Chronic sinusitis, unspecified. The Excludes2 note explains that if the patient also has documented chronic sinusitis, it should be coded in addition to the code for the acute condition.
The codes for documented chronic sinusitis begin with category J32. A fourth character is required to indicate the sinus(es) affected. For example:
J32 Chronic sinusitis
J32.0 Chronic maxillary sinusitis
J32.1 Chronic frontal sinusitis
The codebook has an Excludes2 note associated with chronic sinusitis, reminding us to code acute sinusitis if present and documented. This would give the best clinical picture of a patient who has been diagnosed with chronic sinusitis and presents with an acute episode, as well. List the acute condition first, followed by the code for the chronic condition.
There is also a note at the beginning of category J32 to code additionally for any of the tobacco-related scenarios mentioned at the beginning of the chapter, as well as a reminder to code for any known infectious agents, if documented.
The codes are presented logically, based on anatomy and clinical presentation. Documentation must indicate the anatomy involved and specify whether the condition is acute, chronic, or both. What seems to be a rather straightforward diagnosis can become difficult to code if documentation is not detailed enough for ICD-10-CM.
Although not ideal, when documentation is lacking, ICD-10-CM provides unspecified codes, as well:
J01.90 Acute sinusitis, unspecified
J32.9 Chronic sinusitis, unspecified (sinusitis, NOS)
Now is the time to query providers and vendors about their ICD-10 readiness. Look at your providers’ documentation prior to Oct. 1, 2014 to determine how much education is needed to ensure you are coding correctly.
Jaci Johnson, CPC, CPC-H, CPMA, CPC-I, CEMC, is president of Practice Integrity, LLC. She has been working in the field of medical coding and auditing for 25 years and has been a CPC® since 1994. Johnson teaches PMCC and manages a national client list, providing compliance monitoring for provider documentation. She serves on AAPC’s National Advisory Board, was Virginia’s 2006 Coder of the Year, and is past president of the Richmond, Va., local chapter.