Otolaryngology Coding Alert

Question: A patient came to our office with a chief complaint of hearing loss. Her examination and hearing test had normal results. What diagnosis should we assign?

Colorado Subscriber

Answer: The most appropriate option depends on the circumstances and your provider’s documentation. Here are a few possibilities:

• H91.9- (Unspecified hearing loss …) – Under ICD-9, this was 389.9. Report this code if the audiologist documented in the note that the patient was being seen due to a concern for hearing loss. The fifth character that completes the code specifies the affected ear (right, left, bilateral, or unspecified).
• H93.24- (Temporary auditory threshold shift …) or H93.29- (Other abnormal auditory perceptions …) – Both of these code groups derive from the old 388.40 (Abnormal auditory perception, unspecified). Once again, the final character in each code designates the affected ear/ears. These diagnoses can apply if the patient thinks there might be a hearing problem. You do not need abnormal test results in order to report the diagnosis. 
• Z01.110 (Encounter for hearing examination following failed hearing screening) – Your question does not indicate whether the patient had a failed hearing test such as an automated test like you find in schools or as part of pre-employment exams. However, if documentation shows that the patient has previously failed a hearing exam, you can include Z01.110 (formerly V72.11 in ICD-9) as a secondary or tertiary diagnosis.