Internal Medicine Coding Alert

Question: The internist documented "ringing in head" for a new patient. What diagnosis code applies?

Oklahoma Subscriber

Answer: Submit the best-fitting choice from 388.3x (Tinnitus). The fifth-digit options describe unspecified, subjective (when only the patient hears the ringing sound), and objective tinnitus (when the physician and patient can both hear the ringing sound). Include an additional code for the external cause, if applicable, to identify the reason for the ear condition (such as E928.1, Exposure to noise, for long-term exposure to loud factory noise).

Explanation: Although your internist documented ringing in the head rather than ringing in the ear, both perceptions apply to tinnitus. The ICD-9 notation with 388.3x states "Perception of sound in absence of external noise and may affect one or both ears and/or head."