EmailCoding of acute appendicitis with serositis
Publication Date: June 2020
Implementation Date: 1/07/2020
ICD 10 AM Edition: Eleventh Edition
Query Number: 3521
Please advise on the correct diagnosis code assignment for the following scenario:
Patient admitted for an appendicectomy due to appendicitis. Histopathology states: Florid acute appendicitis and serositis.
Which of the following options is correct?
1. K35.8 Acute appendicitis, other and unspecified
2. K35.3 Acute appendicitis with localised peritonitis
3. K35.8 Acute appendicitis, other and unspecified, and send a clinician query to confirm whether documentation of serositis indicates that patient has peritonitis.
Patient admitted for an appendicectomy due to appendicitis. Histopathology states: Florid acute appendicitis and serositis.
Which of the following options is correct?
1. K35.8 Acute appendicitis, other and unspecified
2. K35.3 Acute appendicitis with localised peritonitis
3. K35.8 Acute appendicitis, other and unspecified, and send a clinician query to confirm whether documentation of serositis indicates that patient has peritonitis.
Response
VICC notes that serositis in the histopathology report may indicate that the surface (serosa) of the appendix was inflamed, rather than indicating a clinical diagnosis of peritonitis.
For the scenario cited, VICC advises to assign K35.8 Acute appendicitis, other and unspecified because the Index entries at Appendicitis do not contain ‘with serositis’.
To assign a code for serositis, serositis would need to meet ACS 0002 Additional diagnoses and be documented as ‘multiple’ or ‘peritoneal’ serositis as these terms are essential modifiers at the lead term Serositis.
Appendicitis with serositis would need to be clarified with the clinician as to whether the serositis was localised or generalised peritonitis in order to assign K35.2 Acute appendicitis with generalised peritonitis or K35.3 Acute appendicitis with localised peritonitis.
For the scenario cited, VICC advises to assign K35.8 Acute appendicitis, other and unspecified because the Index entries at Appendicitis do not contain ‘with serositis’.
To assign a code for serositis, serositis would need to meet ACS 0002 Additional diagnoses and be documented as ‘multiple’ or ‘peritoneal’ serositis as these terms are essential modifiers at the lead term Serositis.
Appendicitis with serositis would need to be clarified with the clinician as to whether the serositis was localised or generalised peritonitis in order to assign K35.2 Acute appendicitis with generalised peritonitis or K35.3 Acute appendicitis with localised peritonitis.
