Still search for a more specific code before resorting to ‘unlisted.’
Fall can bring new allergy symptoms for patients, which can lead to a diagnosis of allergic rhinitis without a pinpointed cause. With ICD-9, you’ve reported this situation with 477.9 (Allergic rhinitis cause unspecified). You’ll have a second option when you begin coding with ICD-10 next month.
What it is: Allergic rhinitis (sometimes called hay fever) is an inflammation of the nasal passages, usually associated with watery nasal discharge and itching of the nose and eyes. The symptoms occur in the nose and eyes and usually occur after exposure to dust, danders, or certain seasonal pollens in people that are allergic to these substances. Sometimes, however, the cause would be unspecified.
ICD-10 changes: Two J codes will describe allergic rhinitis with unspecified cause. These codes are J30.0 (Vasomotor rhinitis) and J30.9 (Allergic rhinitis, unspecified), differentiating vasomotor rhinitis from unspecified allergic rhinitis.
Documentation: Coding guidelines state that for accurate reporting of ICD-9 diagnosis codes, the documentation should describe the patient’s condition, using terminology that includes specific diagnoses as well as symptoms, problems, or reasons for the encounter.
Coder tips: Before coding an unspecified code like J30.9, you should seek out the most appropriate, specific condition first, which could be either J30.1 (Allergic rhinitis due to pollen) or J30.2 (Other seasonal allergic rhinitis). If your physician is not very clear on her diagnosis choices, you should discuss with them to clarify. Never assume. Remember, coders should base their decisions on existing documentation.
Caution: If the physician’s notes state asthma and allergic rhinitis without specifying what they are due to, you should not use J30.9. Instead, you should report J45.20 (Mild intermittent asthma, uncomplicated). Rhinitis (J30.x) excludes allergic rhinitis with asthma (bronchial) – a fact that not many coders necessarily know.