November 21, 2011
Coding for Dermatitis
For The Record
Vol. 23 No. 21 P. 27
Dermatitis, also called eczema, is skin inflammation characterized by swelling, redness, and itching.
Contact dermatitis results from direct contact with a substance that creates an allergic or inflammatory reaction. For coding purposes, the word “contact” is a nonessential modifier for the main term dermatitis. So the specific ICD-9-CM code assignment depends on the causative agent.
There are two types of contact dermatitis. In irritant contact dermatitis, the reaction usually resembles a thermal burn. Common irritants include soap or detergent (692.0); oils and greases (692.1); solvents (692.2); and cleaning products such as bleach (692.4).
Allergic contact dermatitis is caused by exposure to a material to which someone has become hypersensitive. Typically, the person will not react from the initial exposure to the substance. However, repeated exposure may cause sensitivity. Common allergens are rubber (692.4); metals such as nickel (692.83); jewelry (692.83); cosmetics (692.81); poison ivy, oak, or sumac (692.6); and foods such as meat, milk, or fruit (692.5).
If ingesting a food or a drug causes dermatitis, assign code 693.1 or 693.0, respectively. If an allergic reaction occurs due to a drug, it must be determined if the drug was administered and taken correctly by the proper patient. If not, code the condition as a poisoning. In these cases, the drug poison code is sequenced first. These codes are located in the first column of the Table of Drugs and Chemicals in ICD-9-CM. An E code from one of the other columns should be selected to identify the poisoning circumstances. Note that an E code from the Therapeutic Use column is never used with a code from the first column labeled“Poisoning.” The manifestation (eg, dermatitis) of the poisoning is sequenced after the poisoning code.
Some patients develop an allergic reaction to a drug even though it was administered and taken correctly (adverse effect). In these cases, the manifestation is sequenced first followed by an E code from the Therapeutic Use column. The E codes in this column are used only when a patient has an adverse reaction to a drug taken and given properly. The E code to identify the drug involved is mandatory in ICD-9-CM coding. If there is no mention of the drug having been taken incorrectly, it is assumed the reaction is an adverse effect.
Seborrheic dermatitis is characterized by greasy, scaling areas on the scalp, on the sides of the nose, between the eyes, behind the ears, on the external ear canal, in the groin area, or in the armpits. There is no known cause, but it occurs during times of stress, fatigue, and weather extremes and with other skin disorders, such as acne; Parkinson’s disease; a spinal or head injury; or stroke.
Seborrheic dermatitis includes cradle cap (690.11) and dandruff (690.18). Cradle cap is thick, crusty, yellow, scaly skin on a baby’s scalp. If a baby develops seborrheic dermatitis that is not on the scalp, assign code 690.12, Seborrheic infantile dermatitis.
Stasis dermatitis is caused by blood and fluid accumulation in the tissues just beneath the skin. Symptoms include thin, tissuelike skin that thickens as the disease progresses; skin discoloration (red or brown); swelling; itching; macule or patch skin lesions; and inflammation. Open skin ulcers may also develop.
It is assigned to code 459.81. If it occurs with varicose veins, assign code 454.1. If open ulcers are present, assign code 454.2 (AHA Coding Clinic for ICD-9-CM, 2004, third quarter, pp. 5-6 and 1991, second quarter, page 20).
Atopic dermatitis, or atopic eczema (691.8), involves a hypersensitivity reaction within the skin. Symptoms include itching, inflammation, scaling, blisters, redness, swollen patches, and fissured skin.
Neurodermatitis, a form of atopic dermatitis, occurs because of repeated scratching or rubbing of the skin and is characterized by small flat areas (plaques) of various sizes with definite margins that have become thick and leatherlike. Also called lichen simplex chronicus, it is classified to code 698.3. If it is documented as atopic neurodermatitis, assign code 691.8.
Dermatitis can lead to infections such as impetigo or cellulitis. Impetigo (684) is a contagious skin infection characterized by small pus-filled blisters. Cellulitis (681 and 682) is a bacterial infection that involves inflammation of tissues under the skin. The affected area becomes swollen, red, tender, and warm to the touch. Specific code assignment will depend on the site of the cellulitis.
Coding and sequencing for dermatitis are dependent on 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 Audrey Howard, RHIA, of 3M Consulting Services. 3M Consulting Services is a business of 3M Health Information Systems, a supplier of coding and classification systems to more than 5,000 healthcare providers. The company and its representatives do not assume any responsibility for reimbursement decisions or claims denials made by providers or payers as the result of the misuse of this coding information. More information about 3M Health Information Systems is available at www.3mhis.com or by calling 800-367-2447.
Dermatitis in ICD-10-CM
Dermatitis is classified to categories L20 to L30 in ICD-10-CM, with each category specified as follows:
• L20, Atopic dermatitis;
• L21, Seborrheic dermatitis;
• L22, Diaper dermatitis;
• L23, Allergic contact dermatitis;
• L24, Irritant contact dermatitis;
• L25, Unspecified contact dermatitis;
• L26, Exfoliative dermatitis;
• L27, Dermatitis due to substances taken internally;
• L28, Lichen simplex chronicus and prurigo;
• L29, Pruritus; and
• L30, Other and unspecified dermatitis.
Therefore, greater specificity is needed to identify the type and cause of dermatitis. According to the current coding directives in ICD-10-CM, if contact dermatitis is documented, the drug or substance (T36 to T65) is to be coded and sequenced before the contact dermatitis (L23 to L25).
— Audrey Howard