B01.9 - Varicella without complication

Clinical Definition

Acute bacterial sinusitis is an infection and inflammation of the paranasal sinuses caused by bacteria, typically developing within 10 days of onset or worsening after initial improvement.

Documentation Requirements

• Duration (acute = less than 4 weeks)

• Specific pathogen if identified (e.g., Streptococcus pneumoniae)

• Location/affected sinus(es):

  • Maxillary

  • Frontal

  • Ethmoidal

  • Sphenoidal

• Severity indicators:

  • Facial pain/pressure

  • Purulent nasal discharge

  • Nasal congestion

• Any complications present

• Treatment plan (antibiotics prescribed)

Common Synonyms

• Sinus infection

• Bacterial sinus infection

• Acute rhinosinusitis

• Infected sinuses

• "Bad sinus infection"

Coding Conflicts

Excludes1:

• Chronic sinusitis

• Allergic rhinitis

• Viral sinusitis

Excludes2:

• Recurrent acute sinusitis

• Fungal sinusitis

Scribing.io Automation

The AI scribe automatically identifies:

• Temporal markers indicating acute onset

• Specific bacteria mentioned in culture results

• Anatomical terms related to sinuses

• Treatment specifics including antibiotic names

• Symptom duration and progression

• Clear differentiation between bacterial vs. viral etiology based on clinical presentation

Key phrases like "worsening after 5 days" or "purulent discharge" are flagged as supporting documentation for bacterial etiology.