Otolaryngology Coding Alert

Question: Our provider diagnosed a patient with recurrent otitis media and chronic otitis media with effusion. This confuses me because I wasn’t sure which condition she meant. I coded it as H65.196. Was that the right choice?

Delaware Subscriber

Answer: The patient actually might have different types of otitis media in each ear, which could be why your provider documented both conditions. Select diagnosis code H65.197 (Other acute nonsuppurative otitis media recurrent, unspecified ear) for recurrent otitis media if the documentation does not specify the affected ear. Diagnosis H65.499 (Other chronic nonsuppurative otitis media, unspecified ear) is an appropriate code for chronic otitis media with effusion when the affected ear is not noted.

New tactic: Many ICD-10 diagnosis code families include choices for laterality – right, left, bilateral, or unspecified location. Stress to all your providers the importance of including these details in their documentation so you can code more accurately.

For example, the full range of choices for recurrent otitis media include:

• H65.194 – Other acute nonsuppurative otitis media, recurrent, right ear
• H65.195 – … left ear
• H65.196 – … bilateral
• H65.197 – … unspecified.

Check the laterality with your provider before filing the claim. If she can update her documentation to include the affected ears for each type of otitis media, you’ll know that you’re assigning the correct diagnoses.