Otolaryngology Coding Alert

Report otomycosis underlying disease, ICD-9 instructions indicate.

When chart notes contain elusive terms, such as "ear effusions" and "fungal otitis externa," following ICD-9 Coding Conventions will keep you coding like an otolaryngology expert. To submit the correct diagnostic codes for complicated ear diagnoses, remember these rules.

Start With 'A'

First, you should always look up the key terms in ICD-9's Alphabetic Index. Sometimes, you'll find the diagnosis the otolaryngologist listed.

2 Sources Unlock Possible Diagnoses

When you're confronted by anatomic or medical terms that don't appear in ICD-9's Alphabetic Index - and you're not familiar with the phrases - you should use your sources. "Look up the key terms in a good medical dictionary," says John Bishop, PA-C, CPC, MS, CWS, president of Tampa, Fla.-based Bishop and Associates. The information may point you to a listed ICD-9 diagnosis.

Example: An otolaryngologist states that the diagnosis for tubes is "ear effusions." When you look up the key phrase "effusion" in ICD-9's Alphabetic Index, you find no listing. A search for "effusion" produces the following information:

Otitis Media With Effusion

Alternative Names: Glue Ear, OME, Secretory Otitis Media, Serous Otitis Media, Silent Ear Infection, Silent Otitis Media.

Definition: Otitis media is an inflammation of the middle ear. Otitis media with effusion (OME) refers to fluid in the middle ear space, but without the symptoms of an acute infection.

Therefore, you know to look up "otitis media" in ICD-9's Alphabetic Index. When you locate "otitis," you find among the entries one of the above synonyms, "serous":

• serous 381.4
• acute or subacute 381.01
• chronic (simple) 381.10.

The listing points you to nonspecified otitis media code 381.4 (Nonsuppurative otitis media, not specified as acute or chronic) which includes "otitis media: serous" and "otitis media: with effusion." If you have further information as to whether the patient has acute or chronic OM, you can use the specific diagnosis of 381.01 or 381.10.

Alternative: If a medical dictionary doesn't give you the information you need to locate an appropriate listed synonym, go back to the otolaryngologist for more information.

Slanted Brackets Signal Duel Coding

ICD-9's Alphabetic Index sometimes includes additional coding directives. For instance, if you find slanted brackets following a code, you must use these codes together, Bishop says. "You should look up the bracketed code to make sure the entry applies," he says.

Case: After determining that "fungal otitis externa" refers to "otomycosis," you locate the latter phrase in the Alphabetic Index and find this entry:

Otomycosis

• 111.8 [380.15] in
• aspergillosis 117.3 [380.15]
• moniliasis 112.82.

The slanted (italicized) brackets indicate mandatory multiple coding. So, you must assign both codes to fully describe the condition and sequence them in the order listed, according to ICD-9-CM Official Conventions. Therefore for "otomycosis," you would assign 111.8, 380.15 (Chronic mycotic otitis externa).

Be careful: You don't have to report all bracketed codes as part of the valid combination. If you find nonitalicized brackets, the second code is optional.

Indented Phrases Offer More Options

To obtain the correct cross-reference ICD-9 code from the Alphabetic Index, you must read all possible entries within a subcategory. For instance, if you chose to look up "otitis" for "fungal otitis externa" under "externa," you would see "mycotic (chronic) 380.15."

But if you stop there, you could end up painting a partial - and therefore incorrect - diagnostic picture. "It's crucial you also look at the indented phrases following 'mycotic'," Bishop says. You would then see:

• due to
• aspergillosis 117.3 [380.15]
• moniliasis 112.82
• otomycosis 111.8 [380.15].

The indentation means the indented words are directly related to that subcategory. "For instance, chronic otitis externa is a direct manifestation of aspergillosis," Bishop says.

Tabular List Reinforces Code-First Rule

After you find a possible ICD-9 code in the Alphabetical Index, you should always look up the code in the Tabular List. Checking the code's description will allow you to verify your choice and offer further information.

For instance, ICD-9 extends a safety net to coders who overlook the slanted-bracket rule. When you look up 380.15 in the Tabular List, the instruction following the code's definition states that you must "Code first underlying diseases."

Because otomycosis is a manifestation code, you can't use 380.15 alone or as a primary diagnosis. You must first list aspergillosis (117.3, Aspergillosis which includes infection by aspergillus species, mainly A. fumigatus, A. flavus group, A. terreus group) or otomycosis NOS (111.9, Dermatomycosis, unspecified).

Thus, you would need to ask the otolaryngologist for more information about the fungus. If aspergillosis caused the fungal otitis externa, you would report 117.3 and 380.15.

Problem: Most of the time the otolaryngologist doesn't know what type of fungus the patient has until the pathology report comes back. When the otolaryngologist doesn't document any other mycoses information, assign 111.9 and 380.15. This indicates that the mycosis is unspecified at the moment. But, do not continue to carry the unspecified code into further visits once the pathology report has been received and a more specific code can be assigned.

Exclusion Note Screams 'Not This Code'

You should also keep your eyes peeled for exclusion notes following a code. When the instruction "excludes" follows a code, ICD-9 doesn't classify the listed diagnoses to that digit.

Suppose a pathology report identifies candida as the underlying cause of a patient's fungal outer-ear infection.

In this case, you wouldn't use 380.15. The exclusion note following the code indicates ICD-9 doesn't classify candida to 380.15.

Bonus: ICD-9's exclusion note identifies the appropriate code to look up. For otitis externa from candida, you would report 112.82 (Candidiasis; of other specified sites; candidal otitis externa), which includes "otomycosis in moniliasis."