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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