Otolaryngology Coding Alert

Question: Based on a mother's complaint that her 3-year-old son who has tubes is pulling on his ears, my otolaryngologist checks the child's tubes. How should I code the tube check? The tubes are intact, and the tympanostomy's postoperative period has expired.
 
My co-worker wants to assign 388.70 for the diagnosis. But because the examination revealed normal ears and the ENT didn't mention that the child had ear pain, I think we should use V65.5.

Alabama Subscriber

Answer: Even though the otolaryngologist found no infection, you should still use otalgia (such as 388.70, Otalgia, unspecified) as the primary diagnosis. Children don't normally pull on their ears. The behavior indicates that a disturbance, such as fluid, infection or pressure- equalizing tubes in a patient who has them, is causing the child discomfort or pain. Therefore, otalgia appropriately describes the child's condition.
 
You could also assign V41.3 (Problems with special senses and other special functions; other ear problems) in the secondary position to denote other ear problems. Code V41.3 tells the insurer that the otolaryngologist found no reason for the ear pain but concluded that  some other problem exists.
 
Alternatively, you could report 388.70 and V65.5 (Person with feared complaint in whom no diagnosis was made). Using V65.5 as a secondary diagnosis informs the payer that the parent feared that the child had ear pain, but the otolaryngologist found no problem.
 
You shouldn't, however, omit the otalgia diagnosis as you suggested. Because 388.70 identifies the feared condition, coding ear pain paints a more accurate picture than V65.5 alone does.
 
And, because Medicare designates V65.6 as a secondary diagnosis in the ICD-9 manual, you should only use the "worried well" in the primary position when no better diagnosis exists.