EM Coding Alert

You Be the Coder:

Code This ED Earache Encounter

Question: Encounter notes indicate that during a level-three emergency department (ED) evaluation and management (E/M) service, the ED physician diagnosed acute serous otitis media. How should I code this encounter?

Washington Subscriber

Answer: First, report 99283 (Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and low level of medical decision making) for the E/M service. ICD-10-CM coding gets a little trickier, though.

Do this: Go back into the notes and see if you can get answers to these questions:

  • Which ear is affected (left, right, unspecified, both)?
  • Is the condition recurrent?

Then, you’ll be able to choose a diagnosis code from the following options:

  • H65.00 (Acute serous otitis media, unspecified ear)
  • H65.01 (Acute serous otitis media, right ear)
  • H65.02 (Acute serous otitis media, left ear)
  • H65.03 (Acute serous otitis media, bilateral)
  • H65.04 (Acute serous otitis media, recurrent, right ear)
  • H65.05 (Acute serous otitis media, recurrent, left ear)
  • H65.06 (Acute serous otitis media, recurrent, bilateral)
  • H65.07 (Acute serous otitis media, recurrent, unspecified ear).