ICD 10 Coding Alert

Question: My otolaryngologist documented otitis media with effusion for one patient and chronic otitis media with effusion for another. What is the difference, and how do I code them?

New Mexico Subscriber

Answer: The key difference between these two ailments is the duration of the effusion. To find the precise codes for these common conditions, you’ll need to go to the ICD-10-CM Alphabetic Index. Let’s take a closer look:

Otitis media with effusion (OME), also known as serous OM, is swelling and fluid buildup (effusion) in the middle ear without signs of an acute bacterial or viral infection and can occur following an episode of acute otitis media (AOM). The index tells you to look to otitis, media, nonsuppurative to find otitis (acute) with effusion, which leads you to H65.9- (Unspecified nonsuppurative otitis media).

Chronic otitis media with effusion (COME) occurs when fluid (effusion) remains in the middle ear for a long time or builds up repeatedly, even though there is no infection. For this condition, the index tells you to go to otitis, media, nonsuppurative, chronic, which leads you to use H65.49- (Other chronic nonsuppurative otitis media). Here, you’ll see the synonym “chronic otitis media with effusion (nonpurulent),” confirming you have the right code for the condition.