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January 12, 2004

Coding Sinusitis
Vol. 16 No. 1 p. 31

Sinusitis is an inflammation or infection of the mucous membranes of one or more of the sinus cavities located around the face. The infection—which can be caused by bacteria, a virus, or a fungus—causes swelling and obstruction and does not allow for the normal drainage of mucus. Conditions that can lead to sinusitis include allergies, a deviated nasal septum, nasal polyps, and respiratory tract infections such as common colds. When mucus cannot drain from the sinus openings, it creates an environment in which bacteria and viruses are trapped in the sinuses and can grow. Acute sinusitis (ICD-9-CM category 461) occurs when the signs and symptoms last less than four weeks and respond to treatment. Chronic sinusitis (category 473) is defined as lasting longer than 12 weeks or recurring frequently. The fourth digit subcategory depends on the affected sinus (see Table 1).

If the documentation does not specify acute or chronic, the default code assignment is category 473, chronic sinusitis. If the sinusitis is due to fungus, assign code 117.9. Sinusitis with the flu is assigned code 487.1.

Symptoms
The signs and symptoms that most frequently occur in patients with acute sinusitis include the following:
• Pain and pressure in face. Leaning forward or moving the head makes the pain or pressure worse. The location of pain depends on which sinus is affected.
• Nasal congestion
• Yellowish or greenish nasal discharge
• Headache
• Fever
• Cough that produces mucus
• Tooth pain
• Bad breath (halitosis)
• Fatigue
• Ear pain
• Reduced sense of taste or smell

In chronic sinusitis, the patient will typically not experience a fever. Signs and symptoms that are considered major in chronic sinusitis include the following:
• pressurelike pain in the forehead, temples, cheeks, nose, or around or behind the eyes
• difficulty breathing through nose
• thick yellow or green drainage
• reduced sense of smell or taste

Minor signs and symptoms of chronic sinusitis include the following:
• aching in the upper jaw and teeth
• headache
• bad breath
• ear pain
• fatigue
• cough
To diagnose chronic sinusitis, the patient must have 1) at least two of the major signs and symptoms listed above, or 2) one major sign and symptom and at least two of the minor signs and symptoms listed above.

Diagnosis
Sinusitis is typically confirmed by the patient’s explanation of the symptoms and a physical examination. Diagnostic tests that the physician may perform include the following:
• endoscopy to look at nasal passages checking for inflamed secretions or deformities;
• percussion of the sinuses to identify tenderness, which may indicate infection;
• allergy skin tests to determine whether or not allergies are causing the sinusitis; and
• computed tomography detects deep inflammation or infection that may be difficult to detect with an endoscope.

Testing may not be needed for the diagnosis of sinusitis if signs and symptoms and physical findings are typical of sinusitis.

Treatment
Sinusitis may improve on its own with no treatment. However, if treatment is necessary, the goals are as follows:
• improve drainage and reduce swelling;
• relieve pain and pressure;
• clear up infection; and
• prevent the formation of scar tissue and prevent permanent damage.

Over-the-counter medications such as decongestants and pain relievers may treat the signs and symptoms associated with sinusitis. Antibiotics may be prescribed to treat the bacterial infection. Chronic sinusitis may require three to 12 weeks of antibiotics to completely resolve the symptoms. Common antibiotics prescribed include Ampicillin, Amoxicillin, Bactrim, Augmentin, Cefuroxime, and Cefprozil. Decongestants, nasal corticosteroid spray, or oral corticosteroid pills may be taken to relieve stuffiness, shrink inflamed sinus membranes, and reduce the swelling of mucous membranes. The physician may also recommend mucolytics, which are mucus-thinning agents. The underlying allergic condition that contributes to sinusitis may also be treated.

If medications are ineffective in treating sinusitis, surgery may be required. The goal of surgery is to improve the drainage of sinuses by removing whatever is blocking the drainage of mucus. The surgeon may remove infected, swollen, or damaged tissue, bone, polyps, or a foreign object that will allow for better drainage, which makes it less likely for an infection to occur.

Coding and sequencing for sinusitis are dependent upon the physician documentation in the medical record and application of the Official Coding Guidelines for inpatient care. Also, use specific AHA Coding Clinic for ICD-9-CM and American Medical Association CPT Assistant references to ensure complete and accurate coding.

— This information was prepared by Sharon Powell and Audrey Howard, RHIA, both of 3M Health Information Systems (800-367-2447), a leading supplier of coding and classification systems to nearly 4,000 healthcare providers. The company and its representatives do not assume any responsibility for reimbursement decisions or claims denials made by providers or payors as the result of the misuse of this coding information.

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