Consider Additional Dx Code for These Abscesses
Question: Encounter notes indicate that a patient suffers from “cerv spinal cord abscess/methicillin-resistant Staph infection.” I’m not finding this diagnosis in the ICD-10-CM code book. Can you help me locate an appropriate diagnosis code? North Carolina Subscriber Answer: You won’t find those exact words in an ICD-10-CM code descriptor, but “Abscess (embolic) of spinal cord [any part]” is an alternate term for G06.1 (Intraspinal abscess and granuloma). This will be your primary diagnosis code. Don’t stop there: The descriptor for G06.1 also reads “Use additional code (B95-B97) to identify infectious agent.” Since your surgeon documented the infection that caused the abscess, you’ll report B95.62 (Methicillin resistant Staphylococcus aureus infection as the cause of diseases classified elsewhere) along with G06.1. According to the ICD-10-CM code book’s notes under Bacterial and viral infectious agents (B95-B97), “These categories are provided for use as supplementary or additional codes to identify the infectious agent(s) in diseases classified elsewhere.” You should only use these secondary codes if the physician has identified the cause of the infection; if they don’t note it, query the physician about the infection’s cause before using the B95.- (Streptococcus, Staphylococcus, and Enterococcus as the cause of diseases classified elsewhere) through B97.- (Viral agents as the cause of diseases classified elsewhere) codes. Chris Boucher, MS, CPC, Senior Development Editor, AAPC
