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Question: A patient with congestion, thick nasal drainage, facial pain, and a headache presented to the emergency department (ED), and our physician documented diagnoses of the flu and acute maxillary and frontal sinusitis due to the infection. However, the physician didn鈥檛 specify the type of influenza virus.

Which ICD-10-CM codes should I report for this encounter?

Wisconsin Subscriber

Answer: In situations like this, where the patient has both the flu and sinusitis, you鈥檒l assign two diagnosis codes.

First, you鈥檒l assign J11.1 (Influenza due to unidentified influenza virus with other respiratory manifestations) to report the patient鈥檚 flu diagnosis. Code J11.1 features an additional synonym of 鈥淚nfluenza NOS,鈥� which allows you to report this code when the provider doesn鈥檛 give you any specifics beyond the general diagnosis of influenza.

Next, the physician also diagnosed the patient with acute maxillary and frontal sinusitis caused by the flu, so you鈥檒l assign a second code for that per the note under J11.1, which directs you to use an additional code to report an associated sinusitis condition, if applicable, from the J01.- (Acute sinusitis) code category.

You鈥檒l find the J01.- code subcategories are differentiated by which sinuses are affected. Sinuses are air-filled spaces located within the bones of the skull and face centered on the nasal cavity. There are four pairs of paranasal sinuses, each named after the bones that contain them: frontal (lower forehead), maxillary (cheekbones), ethmoid (beside the upper nose), and sphenoid (behind the nose).

When there is inflammation in only one of the four paranasal sinuses, you鈥檒l use the appropriate code from the J01.0- through J01.3- group. When all the sinuses in the head become infected or inflamed, you鈥檒l turn to code J01.4- (Acute pansinusitis). In cases of acute sinusitis involving more than one sinus, but not all of them, ICD-10-CM instructs you to report J01.8- (Other acute sinusitis).

Since the physician diagnosed the patient with both maxillary and frontal sinusitis, you鈥檒l start with J01.8-, but you鈥檒l need to assign a 5th character to complete the code. As the physician didn鈥檛 specify whether the patient experiences maxillary and frontal sinusitis repeatedly, you鈥檒l assign J01.80 (Other acute sinusitis).

Wrap up the claim: For this encounter, you鈥檒l assign J11.1 and J01.80 to report unspecified influenza with acute maxillary and frontal sinusitis. 

Bruce Pegg, BA, MA, CPC, CFPC, Managing Editor, AAPC