Pediatric Coding Alert

Determine how you’d code these common scenarios.

Most pediatric practices can’t let a day pass without logging a diagnosis of otitis media. Ear infections are so common among children that pediatric coders typically have these diagnosis codes committed to memory. However, not every otitis media case is straightforward, and thanks to ICD-10, determining the correct codes to use can be confusing. The following five scenarios can help you determine exactly which diagnoses to use, and when they’re most appropriate.

Know These Common Scenarios

Your most common otitis media cases probably fall into one of the following five scenarios:

1. A child with no ear discomfort who comes in for a well visit and the pediatrician discovers an ear infection
2. The baby with minor discomfort or a low fever who is brought in and the infection is discovered early
3. A child who is in serious discomfort with an advanced and painful ear infection, which is her third ear infection this year.
4. The child who is recovering or has just recovered from a cold and now has a slight fever or fussiness
5. A child who has had recurrent otitis media and your pediatrician refers her for an evaluation by an otolaryngologist for possible surgery.

To determine how to code these scenarios, read further:

1. Acute suppurative otitis media in the left ear discovered at a well visit: Code separately for the ear infection, using an office visit (99211-99215) with modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional 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.

Link the otitis media diagnosis (H66.002, Acute suppurative otitis media without spontaneous rupture of ear drum, left ear) to the office visit, and Z00.121 (Encounter for routine child health examination with abnormal findings) along with the H66.002 to the preventive medicine service. When you indicate that there are abnormal findings be certain to add the abnormality to the preventive care service.

2. Minor discomfort or low fever with acute serous otitis media of the right ear: This ear infection discovered early on by a pediatrician should be reported with H65.01 (Acute serous otitis media, right ear). Code an office visit (99211-99215) for the pediatrician’s work diagnosing the condition.

3. High fever and advanced chronic mucoid otitis media of both ears, which is the child’s third ear infection this year: If the pediatrician classifies the ear infection as chronic, use the chronic mucoid otitis media diagnosis (H65.33, Chronic mucoid otitis media, bilateral) as the primary diagnosis, and the fever (R50.9) as the secondary diagnosis. Technically, you do not have to list the signs and symptoms at all if you have the definitive diagnosis, but if you use both, list the definitive diagnosis first.

The E/M level is determined by what the physician documents, not by the diagnosis codes. However, a complicated diagnosis might result in a higher-level E/M code depending on the doctor’s documentation. The coder must look at the documentation of work performed, not just count the diagnoses.

4. Recovering from cold and diagnosed with acute suppurative otitis media of the right ear with a burst ear drum: An ear infection caused by a viral Upper Respiratory Infection (URI) should be coded with the ear infection diagnosis (in this case, H66.011, Acute suppurative otitis media with spontaneous rupture of ear drum, right ear). Although a URI diagnosis may also be used, it would not necessarily justify billing at a higher level. Code an office visit (99211-99215) based on the documentation.

5. Recurrent tubotympanic infections of the left ear with surgical evaluation needed: Despite the many otitis diagnosis codes, there is no specific ICD-10 code that would describe the pediatrician’s decision to send a patient for surgical evaluation. Recurrence makes a big difference to medical decision-making, however. Once a child has had a certain number in a year, 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. You can code based on time in some scenarios, but will typically choose the most appropriate E/M code along with the diagnosis code (such as H66.12, Chronic tubotympanic suppurative otitis media, left ear).