Don’t Forget to Add Complication Codes in This PE Removal Scenario
Question: One of our providers removed an ear tube from a young patient’s ear after they complained of pain in the ear. What is the correct ICD-10-CM coding for this situation? Revenue Cycle Insider Subscriber Answer: Correct coding for this encounter begins with assigning a code to describe the nature of the encounter, which in this case is to remove the pressure-equalization (PE) tube. You will report this with Z45.82 (Encounter for adjustment or removal of myringotomy device (stent) (tube)). However, the patient is complaining of pain, which is regarded as a complication of the initial surgery to place the PE tube. This needs to follow ICD-10-CM Official Guidelines Section I.C.19.g.2, which states: “Pain associated with devices, implants or grafts left in a surgical site (for example painful hip prosthesis) is assigned to the appropriate code(s) found in Chapter 19, Injury, poisoning, and certain other consequences of external causes. Specific codes for pain due to medical devices are found in the T code section of the ICD-10-CM. Use additional code(s) from category G89 to identify acute or chronic pain due to presence of the device, implant or graft.” In other words, you will need two additional codes to describe the patient’s pain: one to describe the pain as a complication associated with the device, and a second to describe the pain as a postsurgical complication. This will lead you to use the following codes in addition to the encounter code: Bruce Pegg, BA, MA, CPC, CFPC, Managing Editor, AAPC
