Revenue Cycle Insider

Question: A patient presented with severe pain, redness, and excessive tear production in both eyes. The patient stated they were eating chicken wings, and they accidentally rubbed their eyes with the hot sauce still on their hands. The physician diagnosed the patient with bilateral acute toxic conjunctivitis due to the hot sauce.

What diagnosis codes should I assign?

Nebraska Subscriber

Answer: You’ll assign T65.891A (Toxic effect of other specified substances, accidental (unintentional), initial encounter) and H10.213 (Acute toxic conjunctivitis, bilateral) to report the diagnosis.

Code H10.213’s 6^th character of “3” specifies the laterality, which in your case is bilateral or both eyes. Parent code H10.21- (Acute toxic conjunctivitis) features a Code first note instructing you to assign a toxic effects of nonmedicinal substances code from T51-T65 to identify the cause of the injury and the patient’s intent as the primary diagnosis code.

The patient’s reaction to the hot sauce is not due to ingestion, so T65.891A is the most appropriate code choice. With T65.891A, the hot sauce is the other specified substance, but the ICD-10-CM code book doesn’t have a designated code for hot sauces. The 6^th character “1” indicates the patient’s injury was an accident. Lastly, the 7^th character “A” shows the patient is seeking active treatment for the injury.

Mike Shaughnessy, BA, CPC, Development Editor, AAPC