# Otitis Media Visits



## pamtienter (Apr 15, 2009)

I keep hearing different things for ear infection visits. I code for Pediatricians who see a lot of patients with OM. Would you ever code a visit with the diagnosis of OM as a 99214 or due to the nature of the presenting problem, would this always be a 99213? 

Here is one example - what level do you get for the following documentation? (this is a 14 month old and the only other time this provider saw the patient it was for a well child check. No complaints.)
Thanks!

SUBJECTIVE:
History of Present Illness:
Accompanied By:  Father.

Symptom(s):  Fever.  Fussiness.  Rhinorrhea.  Cough.  No emesis.  No
diarrhea.

Fever: Duration: 3 days.
    Max. temp. 101 degrees F.
Fussiness: Duration: Last night.
Rhinorrhea: Duration: 5 days.
Cough: Duration: 5 days.

Acute Medications Used / Exposures:
Acetaminophen.

Past / Family History:
ADR's, Medications, and Problem List reviewed and updated today in the EMR.


OBJECTIVE:
Vital Signs taken today were reviewed on the flowsheet in EMR.
General:   alert but uncooperative during exam.
Eyes:  no injection or drainage.
Ears:  left tympanic membrane normal, right tympanic membrane erythematous
with purulent effusion
Nose:  mild congestion
Oropharynx:  moist mucus membranes without ulcerations; tonsils symmetric
without erythema or exudate.
Neck:  supple without adenopathy or goiter.
Chest:  clear to auscultation; normal effort.
Cardiac:  regular rate without murmur.
Labs/Studies Done Today
No labs done.

ASSESSMENT:
Acute Right Otitis Media.

PLAN:
Symptomatic care.  Encourage fluids and rest. Acetaminophen, ibuprofen, or
other OTC medications only as directed on package. RTC PRN if fevers are
difficult to control, poor fluid intake, or progressive worsening of
symptoms.
Azithromycin (Zithromax) 10 mg/kg today, then 5 mg/kg daily for 4 days.


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## Love Coding! (Apr 15, 2009)

*99214*

I get 99214, new problem to examiner, detailed exam and prescription drug management....

The reason for a level 4?  I do not see OM as a self limited problem (can go away on it's own with no medical intervention)...

That's my opinion...

Thanks!

Denise


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## LOVE2CODE (Apr 15, 2009)

99214 is what I would code...


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## FTessaBartels (Apr 16, 2009)

*Audits as 99214 BUT*

The note audits as a 99214 BUT ...

I wouldn't argue with a physician who wanted to code it as a 99213. Why?  Because it's possible that the prescription was given mostly to mollify Dad rather than because it was needed. (Only the doctor would actually know this for certain.) The doctor spends more time documenting the OTC symptomatic care that he recommends. 

Just my opinion...

F Tessa Bartels, CPC, CEMC


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## cdcpc (Apr 17, 2009)

*I also agree*

I also agree with the above posts.  According to 95 guidelines, I got an expanded problem focused history, detailed exam and moderate MDM =99214.  
Some of my physicians do not feel comfortable charging a 99214 for OM.  Like FTessa says, only the physician and patient knows what went on during the visit.  In cases like this, I advise physicians to make sure documentation matches coding.  If the documentation is at a 99214 level, then that is what should be charged.


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## pamtienter (Apr 17, 2009)

*99213 vs 99214*

This note audits as a 99214 but it was downcoded to a 99213 because of the 'nature of the presenting problem' just being otitis media. The exam is usually detailed and the MDM moderate, so that would qualify as a 99214. It seems the majority of OM visits do come out to be a 99213 so it isn't like all of them are being coded as 4s. If these are babies, between 6 months and 20 months or so, they are usually fussy, have a fever, etc. and since they can't tell you what is wrong, I would think that it could make it a bit more complex visit than the 5 year old that can say their ear hurts and lead the provider more right to the problem. I didn't necessarily agree with this one being downcoded but wanted some other opinions. Thanks.


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## mitchellde (Apr 17, 2009)

I am seeing a 99213, I see the expanded hx and I will go the detailed exam but MDM is low at best and I reall thing more straightforword.  Prescription drug management is only enough to get moderate risk, which is only one component of MDM you will need eith number of dx or complexity of information to also be equal to moderate for this to be moderate MDM and I am not seeing that in this documentation.  How are the rest of you scoring this?


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## RebeccaClendenen (May 28, 2009)

*My opinion*

Dr Jensen covered this recently and he feels that Otitis can be a "new problem".  My opinion is that it is either Self-Limiting or Minor.  I'm not a nurse, but during my time with primary care, I don't recall earaches causing other systemic complications. CPT has a similar situation in their clinical examples and they show it is a 99213.
There is a lot of discussion in regard to this subject.


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## Lisa Bledsoe (May 28, 2009)

I agree with Tessa.
I don't consider otitis self limited or minor as it will most likely not get better on it's own - rx management is required.  As far as MDM it's a new problem to the examiner (# of dx or tx options); no data reviewed; moderate risk for rx...  Based on this I would score the MDM as moderate.
My opinion as it is...


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## Karolina (May 28, 2009)

I also think this codes to be a 99214, the OM being a new problem to the provider. Remember that the code assigned should reflect the work done by the provider; the patient is a fuzzy baby which makes it a bit more labor-intense for the provider. This should be taken into consideration. If the carrier coded it down, I would consider an appeal. If the provider chose to bill a 99213 I would leave it alone, as in the end the provider is responsible for the charge.


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## pamtienter (May 28, 2009)

Thank you all for your input! I appreciate it.


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