Pediatric Coding Alert

In pediatrics, the most typical otitis diagnosis is related to the middle ear and is called otitis media. That category has many specific types of otitis media; ICD9 Codes has created a strict hierarchy for these codes. To select the correct one, note whether the otitis media is chronic or acute; serous (thin or thick fluid), suppurative (with pus), sanguinous (with blood), mucoid (with mucous), or allergic; and whether the eardrum has ruptured. Then, choose the code that combines the relevant conditions. Always use a fifth digit when required.
 
Acute: The acute otitis media diagnosis codes are:
 

381.00 Nonsuppurative otitis media and Eustachian tube disorders; acute nonsuppurative otitis media; unspecified)
 

381.01 acute serous otitis media

381.02 acute mucoid otitis media

381.03 acute sanguinous otitis media

381.04 acute allergic serous otitis media

381.05 acute allergic mucoid otitis media
 

381.06 acute allergic sanguinous otitis media

382.00 Acute suppurative otitis media without spontaneous rupture of ear drum

382.01 Acute suppurative otitis media with spontaneous rupture of ear drum

382.02 Acute suppurative otitis media in diseases classified elsewhere.

The most common is 382.00.
 
Chronic: The chronic otitis media diagnosis codes are:
 

381.10 Chronic serous otitis media, simple or unspecified
 

381.19 other
 

381.20 Chronic mucoid otitis media, simple or unspecified
 

381.29 other

381.3 Other and unspecified chronic nonsuppurative otitis media
 

382.1 Chronic tubotympanic suppurative otitis media
 

382.2 Chronic atticoantral suppurative otitis media
 

382.3 Unspecified chronic suppurative otitis media.

The most common is 381.10.

 
Other: For otitis media that is neither acute nor chronic, report 381.4 (Nonsuppurative otitis media, not specified as acute or chronic), 382.4 (Unspecified suppurative otitis media), or 382.9 (Unspecified otitis media). Use this when otitis media without symptoms is diagnosed such as at a routine preventive-medicine services visit.

Five Common Scenarios

Pediatricians often see five kinds of otitis media cases: 1. the baby with no ear discomfort who comes in for a well visit and an ear infection is discovered, 2. the baby with minor discomfort or a low fever who is brought in and the infection is discovered early, 3. the baby with a high fever that is caused by an advanced and painful ear infection, 4. the baby who is recovering or has just recovered from a cold and now has a slight fever or fussiness, and 5. the toddler who has had recurrent otitis media and now needs an evaluation by an otolaryngologist (ENT) for possible surgery.
 
1. Ear infection discovered at a well visit: Code separately for the ear infection, using an office visit (99211-99215) with modifier -25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) appended, only if you perform a significant and separately identifiable service over and above what you did for the preventive medicine service. If an antibiotic is prescribed, bill the additional charge. Link the otitis media diagnosis (usually 381.01 or 382.00) to the office visit, and V20.2 (Routine infant or child health check) to the preventive medicine service. If an antibiotic is not prescribed and watchful waiting is recommended, do not bill an additional office visit.
 
2. Minor discomfort or low fever: The ear infection discovered early on by a pediatrician is most likely 382.00. Code an office visit (99211-99215).
 
3. High fever and advanced infection: Use the otitis media diagnosis code (382.00) as the primary diagnosis, and the fever (780.6) as the secondary diagnosis. "Technically, you do not have to list the signs and symptoms at all if you have the definitive diagnosis," says Susan Callaway, CPC, CCS-P, an independent coding auditor and trainer in North Augusta, S.C. "But if you use both, list the definitive diagnosis first." The E/M level is determined by what the doctor did and wrote down, not by the diagnosis codes. However, a complicated diagnosis might, indeed, result in a higher-level E/M code depending on the doctor's documentation, Callaway says. The coder must look at the documentation of work performed, not just count the diagnoses.
 
4. Recovering from cold: An ear infection caused by a viral upper respiratory infection (URI) should be coded with the ear infection diagnosis (probably 382.00). Although a URI diagnosis (465.x) may also be used, it would not necessarily justify billing at a higher level, says Richard H. Tuck, MD, FAAP, founding chairman, AAP coding and reimbursement committee, pediatrician, Zanesville, Ohio. Code an office visit (99211-99215).
 
5. Recurrent infections with surgical evaluation needed: Despite the many otitis diagnosis codes, there is no specific ICD-9 code for recurrent ear infections. Recurrence makes a big difference to medical decision-making. Once a child has had a certain number in a year (there is no standard, but Tuck uses more than three within six months), the pediatrician would refer the child to an ENT for possible tubes. This visit will probably require more time because the parent will need an explanation and reassurance. "If the discussion is lengthy, takes up more than 50 percent of the encounter time, and is documented as such, you can change your level of service to a higher level," Callaway says. A special or extra diagnosis is not required. Document the reason for the discussion and the amount of time. Use the appropriate diagnosis code for the type of ear infection the child has that day.

Less Common Scenarios

Report 382.02 as a secondary diagnosis when the otitis media is a manifestation of another disease, such as influenza (487.x) or allergic rhinitis (477.x).
 
Sometimes the ear canal narrows due to repeated infection; use 380.53 (Acquired stenosis of external ear canal; secondary to inflammation) as the secondary diagnosis code when the condition exists with otitis media.

Rechecks

When a child comes back for an otitis media recheck, list the original otitis media diagnosis code in the primary position, and, if the otitis media is resolved, V67.59 (Follow-up examination; following other treatment, other) in the secondary position. The V67.xx diagnosis tells the payer that the treatment for the condition is completed.