Otolaryngology Coding Alert

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Bust These Myths To Overcome TM Rupture Reporting Obstacles

Published on Wed Oct 11, 2023

See how ICD-10 guideline savvy helps to cut through coding confusion.

Coding the various diagnoses related to the ear, nose, and throat can pose a challenge to even the most experienced coders. Identifying the proper code requires an intricate knowledge of anatomy, medical terminology, and the ICD-10 index.

However, it’s also vital that you tie in each and every ICD-10 coding guideline when assessing appropriate reporting of the patient’s condition. While it’s always safe to memorize the guidelines, for many that’s not a practical approach to diagnostic coding success. However, if you don’t have a particular guideline memorized, you should know exactly where to find it in the ICD-10 code book.

Here are two common guideline myths that might be hindering your claim acceptance rate, along with examples involving perforation of the tympanic membrane (TM) to help you sharpen your diagnosis coding skills.

Myth: Never Ignore a Term’s Nonessential Modifiers

Reality: You should not let a nonessential modifier dissuade you from using an otherwise appropriate code. Take, for example, the diagnosis of traumatic central perforation of the right eardrum.

Coding this diagnosis can be tricky due to the traumatic specifier. Your first step is to look up Perforation in the ICD-10 Alphabetic Index; however, it’s at this initial point where coders may find their first hang-up: next to Perforation, perforated, you will find the two supplementary words (nontraumatic) (of).

Refresher: “Parentheses are used in both the Alphabetic Index and Tabular List to enclose supplementary words that may be present or absent in the statement of a disease or procedure without affecting the code number to which it is assigned,” according to ICD-10 guidelines.

“These terms in parentheses, known as nonessential modifiers, may be a clue that you are at the right code, whether you are in the index or the tabular section,” says Sheri Poe Bernard, COC, CPC, CDEO, CRC, CPC-I, CCS-P, of managing consultant for risk adjustment at Granite GRC Consulting in Salt Lake City, Utah. “But while it may affirm your code choice, don’t let a nonessential modifier distract you from using the right code. If the diagnosis you are looking for conflicts with the nonessential modifier, don’t worry. After all, it’s nonessential. That means it is OK to ignore it,” Bernard explains.

The nontraumatic supplementary word could easily dissuade a coder from continuing further down the list of perforation diagnosis codes. However, as long as you have a clear understanding that the supplementary words are not necessarily tied to the underlying term, you may continue to see what coding options are available under perforation.

Perforation, perforated (nontraumatic) (of) ⇒ ear drum will lead you to see Perforation, tympanum. Under Perforation, perforated (nontraumatic) (of) ⇒ tympanum, tympanic (membrane) (persistent post-traumatic) (postinflammatory), you have the option of selecting central.

Note: Here is another avenue where you should not let the supplementary words redirect you. As you can see, one of the supplemental words, persistent post-traumatic, might lead a coder to look elsewhere for a more acute injury code. However, since this descriptor may or may not apply, you should continue under central to find the correct diagnosis code.

Under central, you have options for multiple and total perforations. Since there is no specification as to whether there are multiple or total perforations of the eardrum, you should opt for the default central perforation of the TM code H72.0- (Central perforation of tympanic membrane).

When confirming the code in the Tabular List, you’ll find that you need to include a 5th character to indicate the ear affected, such as H72.01 (… right ear). Also, per the ICD-10 instructional note, you should code first any associated otitis media with H65.- (Nonsuppurative otitis media) through H67.- (Otitis media in diseases classified elsewhere).

Myth: Only Use Combination Codes as a Last Resort

Reality: Quite the opposite. If a combination code applies, use it. “Multiple coding should not be used when the classification provides a combination code that clearly identifies all of the elements documented in the diagnosis,” per ICD-10 guidelines.

A good example that demonstrates this point is an acute recurrent abscess of the left middle ear resulting in perforation of the central eardrum diagnosis.

While this diagnosis seems like a handful on paper, the actual coding mechanism for this diagnosis is fairly straightforward. The main factor to consider in this situation is whether you will be coding both the abscess and perforation diagnoses. According to ICD-10 guidelines, “When an admission or encounter is for a procedure aimed at treating the underlying condition (e.g., spinal fusion, kyphoplasty), a code for the underlying condition (e.g., vertebral fracture, spinal stenosis) should be assigned as the principal diagnosis.”

With this information in hand, one might assume that the middle ear abscess is the underlying diagnosis and, therefore, should be the only diagnosis coded. This would be true unless one of the two following circumstances present themselves:

The perforation of the eardrum is not definitively linked to the abscess or
A combination code exists documenting both the abscess and the perforation.

You will find that, in this example, a combination code does, in fact, exist. Under Abscess ⇒ ear (middle), you will find acute – see Otitis, media, suppurative, acute. Below that listing, you will find recurrent ⇒ with rupture of ear drum, which directs you to H66.01- (Acute suppurative otitis media with spontaneous rupture of ear drum). Make sure to code out to the 6th character to indicate laterality, H66.012 (… left ear).

In an example such as this, coders should not be quick to assume two separate codes, relays Lindsay Della Vella, COC, medical coding auditor and owner of Midnight Medical Coding in Philadelphia. “In the ICD-10 guidelines, it states that a combination code is a single code used to classify ‘two diagnoses or a diagnosis with an associated secondary process or a diagnosis with an associated complication.’ It then goes on to state that ‘multiple coding should not be used when the classification provides a combination code that clearly identifies all the elements documented in the diagnosis.’ So, in this case, H66.012 is correct,” Della Vella explains.

The only additional factor for a coder to consider is the wording of “rupture” versus “perforation” in the descriptor. To make sure that TM rupture and TM perforation are synonymous with each other, simply look up Rupture, ruptured ⇒ ear drum (nontraumatic), which leads you to see also Perforation, tympanum. You may now feel comfortable using code H66.012 to describe an acute recurrent abscess of the left middle ear resulting in perforation of the central eardrum.

Remember to use an additional code to identify smoke exposure, history of tobacco use, tobacco dependence, etc.