ED Coding and Reimbursement Alert

Avoid Denials by Coding Symptoms Supporting Medical Necessity of Flu Visits

This has been a bad year for influenza in many areas of the country and emergency departments (EDs) have seen many patients with flu like symptoms. People without regular physicians, or whose symptoms become too severe to wait to see their primary care physician, end up in the ED waiting room complaining of nausea, fever, aches and pains. You should be careful when assigning ICD-10 codes for the evaluation and management visits and ensure that they only code what is justified in the medical record. Read on to be sure you are inoculated against denials.

Is it Really the Flu, or Just Flu Like Symptoms?

Unless there are complicating circumstances, an emergency physician may not order the viral studies necessary to determine the actual presence of the influenza virus, but he might order a commercial rapid diagnostic test kit. This will not only help confirm the diagnosis but will also help him identify the type of influenza (A, B or C), says Caral Edelberg, CPC, CPMA, CAC, CCS-P, CHC, Founder and Chairman of Edelberg + Associates.

Most of the time in the ED, it is a clinical diagnosis based on presenting symptoms. Symptoms that you will commonly see with an influenza diagnosis include: fever (R50.9, Fever, unspecified) with chills, cough (R05, Cough); malaise (R53.81, Other malaise); headache (R51, Headache); nasal congestion (R09.81, Nasal congestion); and soreness of the throat (J02.9, Acute pharyngitis, unspecified). You might also see gastrointestinal symptoms such as nausea (R11.0, Nausea), vomiting (R11.1-, Vomiting), or both (R11.2, Nausea with vomiting, unspecified) and diarrhea (R19.7, Diarrhea, unspecified), although it is not found in all the cases. The findings of gastrointestinal symptoms and other respiratory symptoms are vital, because they influence reporting the condition correctly in ICD-10.

If Influenza Is Confirmed, Documentation is Key for The Correct Diagnosis

If the physician applies a diagnosis of influenza, to find the appropriate ICD-10 code, you will need to begin your code selections by choosing from three broad code categories: J09 (Influenza due to certain identified influenza viruses), J10 (Influenza due to other identified influenza virus), and J11 (Influenza due to unidentified influenza virus). Careful provider documentation of the current patient presentation is especially important because of the various factors influencing a diagnosis of influenza, Edelberg says.

Category J09 contains four codes:

J09.X1 (Influenza due to identified novel influenza A virus with pneumonia)
J09.X2 (Influenza due to identified novel influenza A virus with other respiratory manifestations)
J09.X3 (Influenza due to identified novel influenza A virus with gastrointestinal manifestations)
J09.X9 (Influenza due to identified novel influenza A virus with other manifestations)

Categories J10 and J11 further expand into a 4th digit classification based on the presence or absence of pneumonia, other respiratory manifestations (such as laryngitis, pharyngitis, and upper respiratory infections), gastrointestinal manifestations, or other manifestations such as encephalopathy, myocarditis, or otitis media.

For example, J10 expands into the following four codes using a fourth digit expansion:

J10.0 (Influenza due to other identified influenza virus with pneumonia)
J10.1 (Influenza due to other identified influenza virus with other respiratory manifestations)
J10.2 (Influenza due to other identified influenza virus with gastrointestinal manifestations)
J10.8 (Influenza due to other identified influenza virus with other manifestations)
J10.0 further expands into the following three codes using a 5th digit expansion based on the type of pneumonia involved:
J10.00 (Influenza due to other identified influenza virus with unspecified type of pneumonia)
J10.01 (Influenza due to other identified influenza virus with the same other identified influenza virus pneumonia)
J10.08 (Influenza due to other identified influenza virus with other specified pneumonia) (Code also other specified type of pneumonia)

Tip: A 5th digit expansion based on the type of manifestation is required under code J10.8:

J10.81 (Influenza due to other identified influenza virus with encephalopathy)
J10.82 (Influenza due to other identified influenza virus with myocarditis)
J10.83 (Influenza due to other identified influenza virus with otitis media)
J10.89 (Influenza due to other identified influenza virus with other manifestations). (Use additional code to identify the manifestation)

Important: Select from the J10 series only when the physician has definitively identified the type of influenza virus. If no type of influenza virus is identified, use a code the J11 series instead.

The J11 series also requires a fourth digit expansion into four codes while J11.0 and J11.8 expand using a fifth digit expansion, similar to the expansion of J10.0 and J10.8 mentioned above.

Also make note that several codes in these three series have notations to "use additional codes," or to "code also," so you will want to watch for those additional instructions where applicable, Edelberg warns.

Add Extra Documentation to Support Emergent Visits for Flu

Providers may wish to send supporting documentation to substantiate the need for ED services for patients with a flu-like illness. These might be modifying factors such as a very young patient, an elderly patient or a patient with chronic conditions affecting treatment, Edelberg adds.