Under HPI the provider says -" Patient presents with a bitten or stung by nonvenomous insect and other nonvenomous arthropod, initial encounter. History of insect sting/bite appears to be consistent with a spider bite. these bites or stings seem to have started around 3 days ago. These are located around the left 2nd toenail. He describes these bites as re, rapidly enlarging, pruritic, and tender. He denies any associated systemic symptoms."
The provider used the ICD 10 - T63.421A.
I do not feel this is correct and questioned it but was told this was correct.
Any help or insight is appreciated.
T63.421A is not correct. That's for an ant bite, and ants weren't mentioned in the documentation at all.
The documentation says "consistent with a spider bite" but in the outpatient setting the guidelines tell us not to code documentation stated as "consistent with":
Based on the available documentation, I'd start in the Alphabetic index with
Bite, Insect which leads you to the S90.46- category:
Since the documentation says that the bite is on the left second toe, I'd use:
S90.465A - Insect bite (nonvenomous), left lesser toe(s), initial encounter
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Just as an exercise, since you mentioned being a new coder. If the provider actually
had documented a definitive spider bite (rather than "consistent with" a spider bite):
Bite, spider (venomous) - see Table of Drugs and Chemicals, by animal or substance, poisoning
Spider (bite) (venom) T63.391-
T63.391A
Toxic effect of venom of other spider, accidental (unintentional), initial encounter
The index and table references to venom or venomous are in parentheses, so the word venom/venomous is nonessential. Just documenting "Spider Bite" would still be T63.391A even if it wasn't specified as a venomous spider.
