Otolaryngology Coding Alert

Here what your physician’s documentation needs to specify.

Infective otitis externa is an infection of the outer ear canal, the passage from the outside of the ear to the eardrum. Infection causes swelling, redness, heat, and pain, and is often associated with a discharge that contains white blood cells. Patient symptoms might range from a slight itch with discomfort to severe pain. Temporary deafness might occur if the swelling and discharge block the ear canal.

Physicians treat out ear infections with ear drops (which usually contain an antibiotic or antiseptic, along with a steroid) or a course of antibiotics. Patients occasionally receive both drops and antibiotics or might also take analgesics to help relieve pain.

ICD-9 Coding Rules: The ICD-9-CM code set provides one diagnosis code for unspecified outer ear infection: 380.10. The ICD-9 manual also directs you to use 380.10 when the physician documents otitis externa (acute), NOS, circumscribed, diffuse, hemorrhagic, or infective NOS. Do not report 380.10, however, for swimmer’s ear, chronic infective otitis externa, or other acute infections of the external ear. Look at other codes in the 380.1x family for those diagnoses.

ICD-10 Changes: Effective Oct. 1, 2014, you won’t have a single code for unspecified outer ear infections. Instead, ICD-10 will differentiate between specific types of problems and the affected ear. Codes for the different conditions will be:

·         H60.00, Abscess of external ear, unspecified ear

·         H60.10, Cellulitis of external ear, unspecified ear

·         H60.319, Diffuse otitis externa, unspecified ear

·         H60.329, Hemorrhagic otitis externa, unspecified ear

·         H60.399, Other infective otitis externa, unspecified ear

Related codes specify infection affecting the left ear, right ear, or both ears. 

You’ll find the diagnoses in ICD-10 under Chapter 8, Diseases of the Ear Mastoid Process. Check the list of exceptions for infectious diseases, congenital malformations, neoplasms, and other conditions represented by different code families.

You should also include an external cause code following the code for the ear condition, if applicable, to identify the ear condition.

Documentation: Physicians usually can diagnose outer ear infection by looking in the patient’s ear. Sometimes the physician takes a specimen by wiping a swab just inside the ear so he can order tests to determine which germ caused the infection.

If your physician orders the lab test, your documentation must include a copy of the laboratory report.

Once ICD-10 goes into effect, physicians will need to be more detailed in their documentation of outer ear infection. Unlike in the past, physician notes will need to specify type of condition the patient has and which ear is affected.

Coder Tips: On your superbill, list each of the available options for outer ear infection to prompt the physician to enter the necessary information. Let your practitioners know that they will need to differentiate between abscess, cellulitis, and different types of external ear infection. If your physician specifies which ear(s) the infection affects, be sure to code to that specificity.