Pediatric Coding Alert

This info will get you beyond 382.9

You can use a specific otitis media (OM) diagnosis to better support your E/M code if you know the OM type and related symptoms, such as allergic, suppurative, serous, mucoid and sanguinous.

Look for Key Terms

Don't let the array of options discourage you. Most general pediatricians use only four (382.00, Acute suppurative otitis media without spontaneous rupture of eardrum; 382.01 , Acute suppurative otitis media with spontaneous rupture of eardrum; 381.01, Acute serous otitis media; and 381.10, Chronic serous otitis media, simple or unspecified) of the more than 20 OM codes.

And, although the pediatrician is ultimately responsible for the OM diagnosis, you can help educate your physician on more specific coding options and requirements if you know the key terms to look for, says Sherry Wilkerson, RHIT, CCS, CCS-P, coding and compliance manager at Esse Health in St. Louis. When the medical record doesn't contain the details that you need, ask your pediatrician for more information.

But, how do you know if you need more information? Let's look at a sample note and see how omitting key details will force you to use 382.9 (Unspecified otitis media) unless you know the right questions to ask.

The problem: An infant presents for a suspected third episode of acute OM within the past two to three months. Coding experts recommend that you answer these four questions to find the correct OM diagnosis.

1. Is the Infection Short- or Long-Term?

To select the OM code, you should first determine whether the patient has acute (brief) or chronic (prolonged) OM. In the above scenario, the pediatrician notes that the OM is acute. "Without further information, you should use 382.9, which includes acute OM," Wilkerson says. Clinically, the patient doesn't appear to have chronic OM, but the note doesn't contain much information, she says.
 
For instance, suppose the pediatrician also states that the child's previous two ear infections hadn't resolved with antibiotics. In this case, because clinical information indicates that the child may have chronic OM, you should ask your physician if the patient has this condition, Wilkerson says.
 
No hard rule defines how many ear infections a child must have before you can use a chronic diagnosis, says Nancy Bischof, MD, a private-practice pediatrician in Lexington, Ky. "I assign chronic OM when a child has an ongoing, intractable infection that wouldn't clear despite several antibiotics courses (three or more)."
 
Even if your pediatrician specifies that the patient has a chronic ear infection, without additional information you will still have to use the same code, 382.9, which includes acute and chronic otitis media not otherwise specified, Wilkerson says.

2. Is the Fluid Infected?

To select a more specific code, you need to know if the middle-ear cavity's fluid is infected. After zeroing in on acute OM in the above example, you should look in the exam note for more information on the fluid's type.
 
Suppose the exam note states that upon otoscopic exam of the tympanic membrane the pediatrician found no infection in the middle-ear cavity's fluid. In this case, you should use a nonsuppurative OM code from the 381.x series (Nonsuppurative otitis media and Eustachian tube disorders), Wilkerson says. Alternatively, if the pediatrician notes that the fluid contains infection or pus, go to the 382.x series for a suppurative diagnosis.

3. What OM-Related Symptoms Exist?

To arrive at the fourth- or fifth-digit code within the 381.x and 382.x series, you have to find the code that combines the relevant OM conditions. These details include noting whether the fluid is serous (thin or thick), suppurative (with pus, purulent), sanguinous (with blood), or mucoid (with mucous), Wilkerson says.

In addition, if an allergy triggered the patient's ear infection, you should also use an allergic diagnosis, such as 381.04 (Acute allergic serous otitis media). If the patient has suppurative OM, you must also know details about any eardrum damage.

4. What Code Identifies the Combined Conditions?

Armed with what the terms mean and what to look for in OM notes, your final step is to find the code that combines the relevant findings. To test your knowledge, read the following exam note and use the chart below to arrive at the ICD-9 code that contains the correct OM combination.

Additional details: The pediatrician notes that she is seeing the infant for a new ear infection. In the exam notes, she states the following findings: yellow and/or red (erythema) color, bulging contour - loss of ossicular landmarks and decreased mobility of membrane, effusion with pus. 
  
Answer: You should report 382.00 (acute purulent). The "new" indication clearly identifies the OM as acute. And, you can tell that the OM is suppurative from the "pus" notation. The pediatrician doesn't mention eardrum damage. The additional details allow you to use 382.00, rather than the original nonspecific 382.9 diagnosis.