ICD-10 Documentation Tips for ENT and Ophthalmology

ICD-10 Documentation Tips for ENT and Ophthalmology

Diagnosis

Documentation Requirements

Cataracts,

Age Related

1) When known or suspected,

document the type of age-related

cataract (senile) as:

-Incipient

-Cortical

-Anterior or posterior subcapsular

polar

-Nuclear

-Morgagnian or

-Combined forms

Diabetic

Eye

Disease

1) Document diabetes type as:

-Type 1

or

-Type 2

2) Document nonproliferative

diabetic retinopathy as:

-Mild

-Moderate

-Severe

-With or without macular edema

Eustachian

Tube

Dysfunction

(ETD)

1) There is no code for ETD

2) If known or suspected, further

specify the ETD as:

-Acute or chronic eustachian

salpingitis

-Eustachian tube obstruction:

intrinsic or extrinsic cartilaginous

or osseous

-Patulous eustachian tube

Neoplasms

1) Document specific site, for

example:

-External upper or lower lip

-Inner aspect of upper or lower lip

-Superior, posterior, lateral, or

anterior wall of nasopharynx

2) Differentiate between primary

and secondary (metastatic) site

3) For secondary sites:

-Document primary site and if it is still

present

Otitis Media

1) Document right or left

2) Document if recurrent

3) Document type, for example:

-Acute versus chronic

-Suppurative versus nonsuppurative

-If acute suppurative, specify if with rupture

of tympanic membrane

-Serous

-Allergic

-Other

Rhinitis

1) When known or suspected,

further specify rhinitis as:

-Acute

-Chronic

-Allergic

-Vasomotor

2) Note that a diagnosis of

rhinitis is coded as chronic

rhinitis. If your intended

diagnosis is acute rhinitis, you

must document acute.

Sinusitis

1) When known or suspected,

further specify sinusitis as:

-Acute

-Chronic

or

-Recurrent

2) Note that a diagnosis of

sinusitis is coded as chronic

sinusitis. If your intended

diagnosis is acute sinusitis, you

must document acute.

3) Document sinus(es) affected:

-Ethmoid

-Frontal

-Maxillary

-Pansinusitis

-Sphenoid

Tobacco

1) Differentiate between:

-Tobacco use/abuse

or

-Dependence

2) Document type of tobacco

product, such as:

-Cigarettes

-Chewing tobacco

-Cigars

3) Differentiate between patients who no

longer smoke and those that do

-Note that "history of smoking" can be an

ambiguous statement

3) Document abnormal blood sugar

control as:

-Inadequately controlled

-Poorly controlled or

-Out of control

4) Document if patient exposed to

second-hand smoke

Drug

Underdosing

1) Document:

-Intentional

versus

-Unintentional

2) Document reason for

underdosing, for example:

-Financial hardship

or

-Age related dementia

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