14 - ICD10 SpecialtyTips ENTICD$10!SPECIALTYTIPS’ OTOLARYNGOLOGY’|4’of’4’...

ICD-‐10 SPECIALTY TIPS

OTOLARYNGOLOGY | 1 of 4

SPECIALTY TIP #14 Otolaryngology Procedures Here are a few helpful tips that make coding for your services more accurate.

• Identify the specific anatomic areas viewed by an endoscope. • Always state laterality. This is especially relevant when treating different conditions and/or performing different procedures for each

side. • Document whether a procedure is open or endoscopic. • Several procedures include the use of an operating microscope. Your documentation of use of the operating microscope, when

applicable, will ensure that this 69990 will be coded when appropriate. • Often it is difficult to determine if a surgery is for purely cosmetic reasons, or whether there is a medical condition that may support

requesting reimbursement from an insurance carrier. o Example: Rhinoplasty to reshape a nose – due to a condition or for cosmetic reasons?

• Your documentation should clearly explain WHY the procedure was done. o Do not just state that you performed a procedure without adequate medical necessity in the form of a codable definitive

diagnosis or signs and/or symptoms. A non-‐codable “rule out” diagnosis might be useful in a denial situation or should there be a request for additional information from a carrier to illustrate your decision making process.

• Balloon antrostomy are considered experimental by the majority of the payers; if removing tissue, biopsy, or if using this technique to get access to complete other procedures, it should be clearly documented in the operative report.

• For balloon sinuplasty there are two criteria: 1) a sinus endoscope must be used to position the balloon prior to and during the cannulation of the ostia, and confirming dilation with the balloon; and 2), that bone and mucosa be moved in such a way as to significantly enlarge the ostium of the sinus that is treated.

o FYI: Health Net, Inc. has added the following documentation criteria to their coverage requirements: § Documentation that the inflammation of the paranasal sinuses has persisted for 12 weeks or longer § Patient has at least one of the following symptoms/signs:

• Anterior or posterior mucopurulent nasal discharge • Nasal obstruction • Facial-‐pain-‐pressure-‐fullness • Headache

§ Patient has at least one finding of chronic sinusitis by CT scan: • Air fluid levels • Mucosal thickening > 2 mm • Opacification

§ Continued symptoms/findings after antibiotic therapy for ≥ 3 weeks, meeting either one of the following: • Antibiotic therapy guided by C & S • Beta-‐lactamase resistant antibiotic

• For 2016, the AMA added a new code for impacted cerumen – 69209 (Removal impacted cerumen using irrigation/lavage, unilateral) to the 69210 (Removal impacted cerumen requiring instrumentation, unilateral)

o Keep in mind, for cerumen removal that is NOT impacted, use an E/M code.

Procedures Documentation Requirements Adenoidectomy & Tonsillectomy

•Document whether: -‐ Partial removal -‐ Complete removal

Aspiration ●Location, laterality and approach •Document whether drainage device was used Fracture Reduction ●Location, laterality and the approach

●Document if internal fixation was used Biopsy ●Location, laterality and approach Parotidectomy ●Location and laterality •Document whether partial or complete

removal and the approach Removal Impacted Cerumen

•Approach: -‐ Percutaneous -‐ Via natural or artificial opening -‐ Endoscopic

Turbinate Surgery • For submucosa resection of the inferior turbinate, report excised/resected/or incised the mucosa (“excised the turbinate(s)” is insufficient)



Diagnosis Documentation tells a story enabling a coder to translate into numbers explaining what you did and why. The more detailed and complete the story, the less difficult it is to support and ask for reimbursement.

• Be sure to designate right, left, or bilateral

• Location, location, location...always be site specific

• Indicate when there is hearing loss and hearing differences in ears • List circumstances of condition such as injury, mishap, medical misadventure, etc. • Indicate when an acquired stenosis of the external ear canal is due to infection, inflammation or trauma. • Document impacted cerumen, if present • Document related, secondary or causal illness whenever appropriate • Document comorbidities that will impact the patient’s condition • Social factors influencing diagnoses

o Note tobacco use, abuse, dependence, past history, or exposure with type of tobacco product (cigarette, chewing, etc.) • For Otitis conditions, always document any associated perforated tympanic membrane

Some most often used diagnoses

Condition Documentation Allergy •Indicate reactions:

-‐ rhinitis -‐ allergic conjunctivitis -‐ atopic dermatitis -‐ urticarial -‐ contact dermatitis -‐ asthma

•Type: -‐ air-‐born substance (J30.89) -‐ alveolitis (extrinsic) (J67.9) -‐ anaphylactic reaction or shock (T78.2-‐) -‐ drug -‐ gastrointestinal (K52.2) -‐ upper respiratory (J30.9)

•Specify the allergen causing the allergic reaction •Indicate lab results

Asthma •Degree of severity -‐ mild -‐ moderate -‐ severe •Frequency -‐ intermittent -‐ persistent

•Asthma is classified as; -‐ mild intermittent (J45.2-‐) -‐ mild persistent (J45.3-‐) -‐ moderate persistent (J45.4-‐) -‐ severe persistent (J45.5-‐) •Level of exacerbation -‐ uncomplicated -‐ acute -‐ status asthmaticus

•Indicate contributing factors -‐ allergic (allergic bronchitis, allergic rhinitis with asthma, extrinsic allergic asthma), -‐ idiosyncratic, -‐ exercise induced, etc.

•Tobacco use/dependence/past history or exposure •Document external factors to establish cause and effect relationship (asthma due to dust, detergent, coal miner’s asthma) •Clarify if associated with COPD

Cholesteatoma •Document laterality: -‐Right -‐Left -‐Bilateral

•Specify site: -‐External ear -‐Middle ear

•Middle ear must be further identified: -‐Attic -‐Tympanum -‐Mastoid -‐Diffuse

Complications •Complications with a procedure or a device require the same specificity of documentation regardless of the initial cause or patient presentation: •Document if the complication is either of procedure or device •Identify the complication as causal to the patient presentation •Clearly identify if this was an expected or unexpected outcome

•It is important to note that not all conditions that occur during, following medical care or surgical are classified as complications. •There must be a cause-‐and-‐effect relationship between the care provided, the condition and an indication in the documentation that it is a “complication.”

Deviated Septum •Note: -‐ acquired (J34.2) -‐ congenital (Q67.4)

Dysphagia •Document phase: -‐ Oral -‐ Oropharyngeal -‐ Pharyngeal -‐ Pharyngo-‐esophageal

•Document if sequela of non-‐traumatic hemorrhage: specify type: -‐ Subarachnoid -‐ Intracerebral -‐ Intracranial

•Document if sequela of: -‐ Cerebral infarction -‐ Cerebrovascular disease

Eustachian Salpingitis •Document type: -‐ Acute (H68.01-‐) -‐ Chronic (H68.02-‐)

•There is no code for Eustachian Tube Dysfunction (ETD) •Specify: Eustachian tube obstruction: -‐intrinsic (H68.12-‐)or extrinsic cartilaginous or osseous (H68.13-‐) -‐Patulous Eustachian tube (H69.0-‐)

Hearing Loss H90.5 -‐ Unspecified sensorineural hearing loss H90.3 -‐ Sensorineural hearing loss, bilateral H90.41 -‐ Sensorineural hearing loss, unilateral, right ear, with unrestricted hearing on the contralateral side H90.42 -‐ Sensorineural hearing loss, unilateral, left ear, with unrestricted hearing on the contralateral side

•Document laterality: -‐ Right -‐ Left -‐ Bilateral •Document type: -‐ Conductive

•Document any hearing differences in each ear •Document when impacted cerumen is present



-‐ Sensorineural -‐ Mixed -‐ Noise-‐induced -‐ Ototoxic (specify agent, e.g. Carboplatin, Erythromycin, etc.)

Hyperthyroidism (Thyrotoxicosis)

•Document: -‐ Diffuse goiter -‐ Single or multinodular -‐ Ectopic thyroid tissue -‐ Due to ingestion of excessive thyroid hormone

•Document: -‐ With thyrotoxic crisis/storm -‐ Without thyrotoxic crisis/storm.

•Document any thyrotoxicosis factitia (drug-‐ induced)

Hypertrophy J35.2 -‐ Hypertrophy of adenoids J35.3 -‐ Hypertrophy of tonsils with hypertrophy of adenoids J34.3 – Hypertrophy of nasal turbinates

Upper Respiratory Disorders • Specify the acuity (i.e. acute, chronic, or recurrent) • Detail the site (e.g. maxillary, pharynx, tonsils, larynx, etc.) • Provide the infectious agent when known (e.g. streptococcus, E. coli, influenza-‐A) • List any hypertrophy or obstruction

• Document underlying or associated conditions (e.g. abscess) • Document any exposure to tobacco smoke

Infections Resistant To Antibiotics

•Specify which antibiotic the organism is resistant to

Mastoiditis •Document laterality: -‐ Right -‐ Left -‐ Bilateral

•Document acuity: -‐ Acute (specify if acute conditions is with OR without complications) -‐ Chronic

•Detail if present: -‐ Subperiosteal abscess -‐ Petrositis -‐ Postauricular fistula List any underlying disease (e.g., infectious or parasitic diseases

Neoplasms •Document specific site: -‐External upper or lower lip -‐Inner upper or lower lip -‐ Superior, posterior, lateral, or anterior wall of nasopharynx

•Differentiate between primary and secondary (metastatic) site

•Secondary site: -‐Document primary site and if it is still present

Obstructive sleep apnea (adult) (pediatric)

G47.33 -‐ Obstructive sleep apnea (adult) (pediatric)

Otitis Externa •Document laterality: -‐ Right -‐ Left -‐ Bilateral •Document acuity: -‐ Acute -‐ Chronic

•Document infective type: -‐ Abscess -‐ Cellulitis -‐ Malignant -‐ Diffuse -‐ Hemorrhagic -‐ Swimmers ear -‐ Cholesteatoma

•Document non-‐infective type: -‐ Actinic -‐ Chemical -‐ Contact -‐ Eczematoid -‐ Reactive

Otitis Media H66.90 -‐ Otitis media, unspecified, unspecified ear H66.91 -‐ Otitis media, unspecified, right ear H66.92 -‐ Otitis media, unspecified, left ear H66.93 -‐ Otitis media, unspecified, bilateral •Document laterality: -‐ Right -‐ Left -‐ Bilateral

•Document acuity: -‐ Acute -‐ Subacute -‐ Chronic -‐ Recurrent •Document Type: -‐ Serous -‐ Mucoid -‐ Allergic -‐ Atticantral -‐ Tubotympanic

•Differentiate: -‐ Non-‐suppurative -‐ Suppurative •Document any tobacco use, abuse, dependence, or exposure •Document underlying diseases (viral infection, influenza, etc.) •Document: -‐ With or without spontaneous rupture of eardrum -‐ Myringitis

Otitis Media, Suppurative

H66.001 -‐ Acute suppurative otitis media without spontaneous rupture of ear drum, right ear H66.002 -‐ Acute suppurative otitis media without spontaneous rupture of ear drum, left ear H66.003 -‐ Acute suppurative otitis media without spontaneous rupture of ear drum, bilateral H66.004 -‐ Acute suppurative otitis media without spontaneous rupture of ear drum, recurrent, right ear H66.005 -‐ Acute suppurative otitis media without spontaneous rupture of ear drum, recurrent, left ear H66.006 -‐ Acute suppurative otitis media without spontaneous rupture of ear drum, recurrent, bilateral H66.007 -‐ Acute suppurative otitis media without spontaneous rupture of ear drum, recurrent, unspecified ear H66.009 -‐ Acute suppurative otitis media without spontaneous rupture of ear drum, unspecified ear H66.011 -‐ Acute suppurative otitis media with spontaneous rupture of ear drum, right ear

H66.10 -‐ Chronic tubotympanic suppurative otitis media, unspecified H66.11 -‐ Chronic tubotympanic suppurative otitis media, right ear H66.12 -‐ Chronic tubotympanic suppurative otitis media, left ear H66.13 -‐ Chronic tubotympanic suppurative otitis media, bilateral H66.20 -‐ Chronic atticoantral suppurative otitis media, unspecified ear H66.21 -‐ Chronic atticoantral suppurative otitis media, right ear H66.22 -‐ Chronic atticoantral suppurative otitis media, left ear H66.23 -‐ Chronic atticoantral suppurative otitis media, bilateral H66.3x1 -‐ Other chronic suppurative otitis media, right ear

• Specify the acuity (acute, subacute, chronic, or recurrent) • Detail the type (e.g. serous, mucoid, allergic, atticoantral, tubotympanic, etc.) • Differentiate non-‐suppurative and suppurative • Identify laterality (i.e. right, or bilateral) • Report any spontaneous rupture of the eardrum or myringitis • State any related tobacco use, abuse, dependence, past history, or smoke exposure (e.g. second hand, occupational, etc.) • List any underlying disease (e.g. viral infection, influenza, scarlet fever)



H66.012 -‐ Acute suppurative otitis media with spontaneous rupture of ear drum, left ear H66.013 -‐ Acute suppurative otitis media with spontaneous rupture of ear drum, bilateral H66.014 -‐ Acute suppurative otitis media with spontaneous rupture of ear drum, recurrent, right ear H66.015 -‐ Acute suppurative otitis media with spontaneous rupture of ear drum, recurrent, left ear H66.016 -‐ Acute suppurative otitis media with spontaneous rupture of ear drum, recurrent, bilateral H66.017 -‐ Acute suppurative otitis media with spontaneous rupture of ear drum, recurrent, unspecified ear H66.019 -‐ Acute suppurative otitis media with spontaneous rupture of ear drum, unspecified ear

H66.3x2 -‐ Other chronic suppurative otitis media, left ear H66.3x3 -‐ Other chronic suppurative otitis media, bilateral H66.3x9 -‐ Other chronic suppurative otitis media, unspecified ear H66.40 -‐ Suppurative otitis media, unspecified, unspecified ear H66.41 -‐ Suppurative otitis media, unspecified, right ear H66.42 -‐ Suppurative otitis media, unspecified, left ear H66.43 -‐ Suppurative otitis media, unspecified, bilateral

Rhinitis •Document acuity: -‐ Acute -‐ Chronic •Document: -‐ With sore throat -‐ Allergic with asthma (specify if exacerbation or status asthmaticus)

•Document type: -‐ Allergic (due to food or pollen, seasonal, nonseasonal, perennial) -‐ Infective -‐ Pneumococcal -‐ Syphilitic -‐ Tuberculosis -‐ Vasomotor

•Document any tobacco use, abuse, dependence, or exposure

Sinusitis •Document acuity: -‐ Acute -‐ Chronic -‐ Acute -‐ Recurrent •Link lab results (culture, infectious organism, sensitivity)

•Document location: -‐ Maxillary -‐ Frontal -‐ Ethmoidal -‐ Sphenoidal -‐ Pansinusitis

•Document any tobacco use, abuse, dependence, or exposure

Tinnitus, Dysfunction of Eustachian Tube

•Document laterality: -‐ Right -‐ Left -‐ Bilateral

•Document: -‐ Underlying disease or injury •Document: -‐ Circumstances around any injury, medical misadventure or mishap causing an ear condition

•Document any tobacco use, abuse, dependence, or exposure •Document any hearing differences in each ear

Tobacco Use Disorder •Document type: -‐ Cigarettes -‐ Chewing tobacco -‐ Other •Delineate between: -‐ Tobacco use/abuse -‐ Tobacco dependence

•Document state of dependence: -‐ In remission -‐ With withdrawal -‐ Without withdrawal

•Document if used during pregnancy, childbirth, Puerperium •Describe history, including product and time

Tonsillitis H66.90 -‐ Otitis media, unspecified, unspecified ear H66.91 -‐ Otitis media, unspecified, right ear H66.92 -‐ Otitis media, unspecified, left ear H66.93 -‐ Otitis media, unspecified, bilateral J35.03 – Chronic tonsillitis and adenoiditis

•Document acuity: -‐ Acute -‐ Chronic (with or without adenoiditis) -‐ Recurrent •Document type/cause: -‐ Diphtheritic -‐ Hypertrophic (with or without adenoiditis) -‐ Staphylococcal -‐ Tuberculosis -‐ Vincent's

•Differentiate between: -‐ Tonsillitis -‐ Peritonsillar abscess -‐ With or without adenoiditis •Document any tobacco use, abuse, dependence, or exposure

Tympanic Membrane Disorders

•List any associated otitis media •Specify any related trauma and associated circumstances surrounding the injury

•Specify perforations: -‐ Central -‐ Attic -‐ Multiple -‐ Total -‐ Other

•Specify myringitis as: -‐ Acute -‐ Bullous -‐ Chronic •Specify atrophic tympanic membrane as flaccid or non-‐flaccid

Upper Respiratory Disorders

•Document acuity: -‐ Acute -‐ Chronic -‐ Subacute -‐ Recurrent

•Document site: -‐ Maxillary -‐ Pharynx -‐ Larynx -‐ Other

•Specify infectious agent, when known (e.g. Streptococcus, influenza A) •Document hypertrophy or obstruction •Document underlying or associated conditions (e.g. COPD, abscess, etc.)

Vestibular Function Disorder

•Identify: -‐ Meniere’s Disease (H81.0-‐) -‐ Benign Paroxysmal Vertigo (H81.1-‐) -‐ Vestibular Neuronitis (H81.2-‐) -‐ Vertigo (R42)

•Differentiate between: -‐ Labyrinthitis (H83.0-‐) -‐ Labyrinthine Fistula (H83.1-‐) -‐ Labyrinthine Dysfunction (H83.2-‐)

The information provided is only intended to be a general summary and not intended to take place of either written law or regulations.

14 - ICD10 SpecialtyTips ENTICD$10!SPECIALTYTIPS’ OTOLARYNGOLOGY’|4’of’4’...

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