Resolved Index icd10

[MaryW_64032]

If a dx can’t be indexed and it doesn’t tell you to see condition , does it get coded ? example mucosal thickening of the ethmoid air cells? Thank you

 

[Lori]

It may be a symptom of another diagnosis perhaps hard to tell without further documentation.

H95.139
Mucosal cyst of postmastoidectomy cavity, unspecified ear

Or

J01.20 Acute ethmoidal sinusitis, unspecified

Perhaps this free resource will help:

Abstracting the Basis of Coding: Click Here to Download

 

[MaryW_64032]

It may be a symptom of another diagnosis perhaps hard to tell without further documentation.

H95.139
Mucosal cyst of postmastoidectomy cavity, unspecified ear

Or

J01.20 Acute ethmoidal sinusitis, unspecified

Perhaps this free resource will help:

Abstracting the Basis of Coding: Click Here to Download

Comes in with nasal pain and that’s the only finding. I thought there was a guideline of it couldn’t be indexed it’s not coded ?

 

[Lori]

There is no guideline for if it couldn’t be indexed it’s not coded.

You can code the nasal pain perhaps if no definitive DX is established depending on the setting.

Use of Sign/Symptom/Unspecified Codes Sign/symptom and “unspecified” codes have acceptable, even necessary, uses. While specific diagnosis codes should be reported when they are supported by the available medical record documentation and clinical knowledge of the patient’s health condition, there are instances when signs/symptoms or unspecified codes are the best choices for accurately reflecting the healthcare encounter. Each healthcare encounter should be coded to the level of certainty known for that encounter.

If a definitive diagnosis has not been established by the end of the encounter, it is appropriate to report codes for sign(s) and/or symptom(s) in lieu of a definitive diagnosis. When sufficient clinical information isn’t known or available about a particular health condition to assign a more specific code, it is acceptable to report the appropriate “unspecified” code (e.g., a diagnosis of pneumonia has been determined, but not the specific type). Unspecified codes should be reported when they are the codes that most accurately reflect what is known about the patient’s condition at the time of that particular encounter. It would be inappropriate to select a specific code that is not supported by the medical record documentation or conduct medically unnecessary diagnostic testing in order to determine a more specific code

The importance of consistent, complete documentation in the medical record cannot be overemphasized. Without such documentation, accurate coding cannot be achieved. The entire record should be reviewed to determine the specific reason for the encounter and the conditions treated.

Code assignment and Clinical Criteria The assignment of a diagnosis code is based on the provider’s diagnostic statement that the condition exists. The provider’s statement that the patient has a particular condition is sufficient. Code assignment is not based on clinical criteria used by the provider to establish the diagnosis.

Section II includes guidelines for the selection of principal diagnoses for non-outpatient settings.
Section III includes guidelines for reporting additional diagnoses in non-outpatient settings.
Section IV is for outpatient coding and reporting.

It is necessary to review all sections of the guidelines to fully understand all of the rules and instructions needed to code properly.

 

[MaryW_64032]

Thank you for the clarification