Code: J01.90
Description: Acute sinusitis, unspecified
Context: This code is used when a patient has acute sinus inflammation without a specified sinus location (maxillary, frontal, etc.).
Guidelines for Proper Use
- Acute condition: Use for sinus infections of less than 4 weeks’ duration.
- Unspecified location: Apply when the provider does not specify which sinus is affected.
- Include symptoms: Typically associated with nasal congestion, headache, facial pain, or fever.
- Differentiate from chronic: Do not use for chronic or recurrent sinusitis.
- Primary diagnosis: Often used as the primary diagnosis for antibiotic treatment visits.
Common Misuses of J01.90
- Using for chronic sinusitis: Use J32.9 instead for chronic cases.
- Missing clinical documentation: Must support acute onset and typical infectious symptoms.
- Combining with allergic rhinitis: Use separate codes if allergic rhinitis is also diagnosed.
- Overuse for all nasal symptoms: Only use when infection is confirmed or strongly suspected.
Notes / Documentation Tips
- Note duration: Document that symptoms are acute (<4 weeks).
- Identify etiology if possible: Viral or bacterial if known.
- Include sinus exam findings: Tenderness, discharge, or imaging results.
- Record treatment plan: Antibiotics, nasal spray, or decongestant use.
- Specify recurrence if applicable: Use additional codes for recurrent episodes.
