Coding case study: Sinusitis

May 2, 2018
Renee Dowling
Volume 95, Issue 08

Getting paid requires accurate documentation and selecting the correct codes. In our Coding Case Studies, we will explore the correct coding for a specific condition based on a hypothetical clinical scenario.

Getting paid requires accurate documentation and selecting the correct codes. In our Coding Case Studies, we
will explore the correct coding for a specifi c condition based on a hypothetical clinical scenario.

Clinical scenario

History:
The patient has a respiratory and sinus illness, with four days of worsening cough productive of green sputum. He has had yellow sinus drainage, sinus congestion, and sinus pressure. No fever or chills. No flu-like symptoms. He used Mucinex over the weekend. No neck pain or stiffness.

Review of SystemsConstitutional: Negative for activity change, appetite change, chills, diaphoresis, fatigue, fever, and unexpected weight change.
HENT: Positive for congestion, rhinorrhea (yellow), sinus pain (frontal) and sinus pressure.
Eyes: Negative for photophobia, pain, discharge, redness, itching, and visual disturbance.
Respiratory: Positive for cough (productive of green sputum, no blood).
Cardiovascular: Negative for chest pain, palpitations, and leg swelling.
Allergic/Immunologic: Negative for environmental allergies.
Neurological: Positive for headaches (+Sinus HA).

Physical ExamConstitutional: He is oriented to person, place, and time. No distress.
Head: Normocephalic and atraumatic.
Ears: Tympanic membrane and ear canals normal.
Nose: Mucosal edema and rhinorrhea present. Right sinus exhibits frontal sinus tenderness. Right sinus exhibits no maxillary sinus tenderness. Left sinus exhibits frontal sinus tenderness. Left sinus exhibits no maxillary sinus tenderness.
Mouth/Throat: Oropharynx is clear and moist and mucous membranes are normal.
Eyes: Conjunctivae and EOM are normal. Pupils are equal, round, and reactive to light. No scleral icterus.
Neck: Normal range of motion and phonation normal.
Cardiovascular: Normal rate, regular rhythm.
Lymphadenopathy: He has no cervical adenopathy

Assessment and Plan

  • Bacterial sinusitis
  • Acute bacterial bronchitis

Push fluids
Continue Mucinex DM
Zpak antibiotic as directed until all gone.

Documentation requirements
When documenting sinusitis, include:
Temporal factors: Acute, acute recurrent, chronic
Location Frontal, ethmoidal, sphenoidal, maxillary, other

ICD-10 codes
J01.00 Acute maxillary sinusitis, unspecified
J01.01 Acute recurrent maxillary sinusitis
J01.10 Acute frontal sinusitis, unspecified
J01.11 Acute recurrent frontal sinusitis
J01.20 Acute ethmoidal sinusitis, unspecified
J01.21 Acute recurrent ethmoidal sinusitis
J01.30 Acute sphenoidal sinusitis, unspecified
J01.31 Acute recurrent sphenoidal sinusitis
J01.80 Other acute sinusitis
J01.81 Other acute recurrent sinusitis
J01.90 Acute sinusitis, unspecified
J01.91 Acute recurrent sinusitis, unspecified
J32.0 Chronic maxillary sinusitis
J32.1 Chronic frontal sinusitis
J32.2 Chronic ethmoidal sinusitis
J32.3 Chronic sphenoidal sinusitis
J32.8 Other chronic sinusitis
J32.9 Chronic sinusitis, unspecified
Use additional code to identify:
❚ exposure to environmental tobacco smoke (Z77.22)
❚ infectious agent (B95-B97)
❚ tobacco dependence (F17-F17.299)
❚ tobacco use (Z72.0)

Diagnosis codes
J01.10 Acute frontal sinusitis, unspecified
J20.8 Acute bronchitis due to other specified
organisms
B96.89 Oth bacterial agents as the cause of diseases classd elswhere