ICD 10 Coding Alert

Question: I have an otitis media chart in front of me and I’m confused. I know it’s otitis media of the left ear, but I don’t know what type it is (serous, sanguinous, suppurative, etc.) What should I be looking for?

Arkansas Subscriber

Answer: One of the reasons you do not know which type of otitis media (OM) the patient has is that your provider is not documenting to the highest level of specificity. They should be documenting that the OM is suppurative or serous, etc. But you can interpret your doctor’s notes in order to more easily report OM diagnosis, as long as you get to know a few key terms that you can use when your providers don’t give you the specifics you need.

Nonsuppurative vs. suppurative: Simply put, if your physician documents that one or both of the patient’s ears is oozing pus, you will look to using a code from H66.- (Suppurative and unspecified otitis media).

A similar term to suppurative is purulent. If you see this term in your otolaryngologist’s documentation, you can not only go straight to the H66.- codes, but also straight to H66.4- (Suppurative otitis media, unspecified) because purulent otitis media NOS is a synonym for the code.

Conversely, you will code noninfected ear conditions with H65.- (Nonsuppurative otitis media). Nonsuppurative ear conditions also feature secretions, which are either serous, mucoid, or sanguinous. Serous fluid is a thin, clear, or yellowish fluid; whereas mucoid fluid, as its name implies, is a thicker, mucus discharge. Sanguinous fluid is a reddish discharge indicating blood is present in the fluid.

Fortunately, for ICD-10 purposes, the terms are subordinate to your provider’s documentation of OM severity. For acute serous OM, you’ll use H65.0- (Acute serous otitis media); and for acute mucoid and sanguinous OM, you’ll use H65.19- (Other acute nonsuppurative otitis media).