Otolaryngology Coding Alert
Know When, When Not to, Include Supplementary Diagnoses
Question: The provider states that she removed pus debris under a microscope for a patient with a right ear infection. What ICD-10-CM code should I report for debris in the ear? Georgia Subscriber Answer: Since the pus and debris are both the result of an ear infection, an ICD-10-CM code to report the infection will include any symptomatic physiological responses that commonly occur with an ear infection. Since pus and debris removal is a routine service for patients with an ear infection, you should consider the pus and debris redundant secondary diagnoses. In order to code an ear infection, you’ll first want to determine what level of the ear the infection occurs. Assuming it’s the middle ear, you’ll search the ICD-10-CM index for Infection ⇒ ear (middle), which will lead you to “see also Otitis media.” Assuming there are no further specifying diagnostic terms, Otitis (acute) ⇒ media (hemorrhagic) (staphylococcal) (streptococcal) leads you to code H66.91 (Otitis media, unspecified, right ear). Coder’s note: Remember that the term “acute” listed in parenthesis next to the index term “Otitis” is what’s known as a “nonessential modifier.” This means that it does not need to be included in your diagnosis in order to report the respective diagnosis code. Rather, the term in parenthesis is a helpful, but nonessential reference that informs individuals that are working under an acute otitis diagnosis that they should also begin at the main term “Otitis (acute).”
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Know When, When Not to, Include Supplementary Diagnoses
Question: The provider states that she removed pus debris under a microscope for a patient [...]
