ED Coding and Reimbursement Alert

Sometimes you may have to go beyond the initial issue to find the right code.

Sure, you can select the code for allergic rhinitis when you see the patient in your ED. But what happens when the physician diagnoses fungal debris as an adjunct to the rhinitis? Many conditions go beyond the main ICD-10 code to make coding these cases more complex, and we’ve got the scoop on what to do when you see these uncommon situations in your emergency department.

Check out these examples and determine whether you know how to code these situations.

Dig Deeper for Allergic Rhinitis with Fungal Debris

If your physician documents a diagnosis of “allergic rhinitis with fungal debris,” you’ll have to go beyond the standard J30.9 (Allergic rhinitis, unspecified) option. In evaluating this condition, keep in mind that the fungal debris is not a separate diagnosis from the rhinitis, but rather a product of the rhinitis. However, this doesn’t mean that you should not consider it when making your final coding considerations. That’s because the fungal debris reveals that this is a form of allergic fungal rhinitis, and you should code it accordingly.

So, instead of reporting J30.9 and disregarding the fungal debris as a symptom of the allergic rhinitis, you should be reporting J30.89 (Other allergic rhinitis) for a lack of a more specific code for allergic fungal rhinitis. “There is no code specific to allergic fungal rhinitis, which is not a fungal infection, but an allergic reaction, and reported with J30.89,” says Sheri Poe Bernard, CPC, of Poe Bernard Consulting in Salt Lake City, Utah. “When documentation simply lists ‘fungal debris’ in a patient with allergic fungal sinusitis, it should be considered an incidental finding, and no additional code is needed,” Bernard explains.

Don’t forget: Once the fungal debris has been evaluated by pathology, you will report the appropriate “B” code for the fungus that is present, says Barbara J. Cobuzzi, MBA, CPC, COC, CPC-P, CPC-I, CENTC, CPCO, AAPC Fellow, of CRN Healthcare in Tinton Falls, New Jersey.

Don’t Cut Corners with Unclear Diagnoses

Suppose you review an EHR report without a diagnosis that meets the CPT^® code’s Local Coverage Determination (LCD) requirement, but the diagnosis on a radiology order that the ED physician wrote does meet the LCD requirement. Should you select that second diagnosis code to ensure your ED claim gets paid?

The answer is no — you should not submit a claim with a diagnosis the provider does not document in the EHR. If the order includes a different diagnosis than what’s included in the report, then you could send the report back for an addendum before submitting the ordering diagnosis.

However, if the impression yields significant findings that render the ordering and/or indicating diagnoses insignificant, then do not include either set of diagnoses. You should not report secondary diagnoses considered insignificant or irrelevant. With respect to redundancy involving signs and symptoms, have a look at this ICD-10-CM guideline:

• Signs and symptoms that are associated routinely with a disease process should not be assigned as additional codes, unless otherwise instructed by the classification.

However, according to the following ICD-10-CM guideline, it’s up to your discretion if you choose to include signs and symptoms that are unrelated to the underlying diagnosis:

• Additional signs and symptoms that may not be associated routinely with a disease process should be coded when present.

While the guidelines only make references to signs and symptoms, you should take a similar approach to secondary conditions included in the indication or as an ordering diagnosis. If the ordering diagnosis does not meet these sets of criteria to be included as a primary or secondary diagnosis, you should not go through the trouble of getting an addendum to the report.

Avoid Using Dermatitis, Eczema Terms Interchangeably

In some cases, you may see a note that refers to both “dermatitis” and “eczema” for the same rash. Although some providers may document these codes interchangeably due to the L20-L30 section’s notation as referring to “Dermatitis and eczema,” the reality is that there is a clinical difference between the two, and if you see both terms noted in the chart, you should ask the physician to clarify the patient’s actual condition.

Further confusion arises when you examine the L25.- (Unspecified contact dermatitis) codes more closely. Here, the “unspecified” aspect of these codes does not mean the cause of the dermatitis is unknown.

Rather, it refers to the nature of the contact dermatitis instead of its cause. In fact, the code group contains a number of causal codes that are similar to the allergic- and irritant-contact dermatitis codes, including codes for dermatitis caused by cosmetics (L25.0), drugs in contact with skin (L25.1), dyes (L25.2), and chemical products like cement and insecticides (L25.3).

To add to the confusion, L25.5 (Unspecified contact dermatitis due to plants, except food) does not include nettle rash, which has its own code: L50.9 (Urticaria, unspecified). Fortunately, there is an Excludes1 note that accompanies L25.5 reminding you of the fact.