Pediatric Coding Alert

Hear the difference between otalgia and otitis media.

Pediatric conditions related to the ear are almost as common as colds, and knowing how to accurately code for these specialized conditions is one way to get your clean claim rate back on track.

Here, we’ve busted three common myths about pediatric ear conditions to help you start the year off right.

Myth 1: Cerumen removal always calls for 69209 or 69210.

While 69209 (Removal impacted cerumen using irrigation/ lavage, unilateral) and 69210 (Removal impacted cerumen requiring instrumentation, unilateral) are common cerumen removal CPT^® codes, the decision to use either of them depends on the type of instrument the pediatrician used to remove the cerumen and whether it was impacted.

If the cerumen was not impacted, neither code is appropriate. Instead, CPT^® guidelines instruct you to use an appropriate evaluation and management (E/M) code from 99202-99205 or 99212-99215 (Office or other outpatient visit for the evaluation and management of a/an new/ established patient …).

If the cerumen removed in the encounter is indeed impacted, which you must document with H61.20 (Impacted cerumen, unspecified ear), H61.21 (… right ear), H61.22 (… left ear), or H61.23 (… bilateral), you must then choose the CPT^® code that most closely described the actual procedure your provider performed. Note that if your provider used instrumentation, you cannot use 69209 even if they performed irrigation prior to the instrumentation removal.

Modifier alert: CPT^® instructs you to use modifier 50 (Bilateral procedure) if the removal is bilateral. However, modifier choice in this example is payer specific. Some may want you to report bilateral cerumen removal on two lines with modifier 50 on the second line. Others may also prefer two lines with the RT modifier on one line and the LT modifier on the other, while Medicare and payers that recognize Medicare guidelines many want you to use modifier XS (Separate structure …). So, you will have to check payer guidelines before submitting your claim for this service.

Myth 2: Otalgia and otitis media are interchangeable terms.

Otalgia and otitis media (OM) are not interchangeable terms. They are two distinct medical terms that refer to different conditions.

Otalgia: This is a general term for ear pain. This pain can be caused by various conditions, not all of which are directly related to the ear. For example, problems in the throat, jaw, or teeth can also cause ear pain.

Otitis media: This term refers to an infection or inflammation of the middle ear. OM is common in children and can cause symptoms such as ear pain (otalgia), fever, and hearing difficulties.

So, while otalgia refers to the symptom of ear pain, otitis media is a specific condition that can cause this symptom among others.

Example: Let’s say a parent brings a toddler to see the provider. The child is complaining of pain in the right ear. How you code this “would depend on the medical decision making of the provider,” says Chelle Johnson, CPMA, CPC, CPCO, CPPM, CEMC, AAPC Fellow, billing/credentialing/auditing/ coding coordinator at County of Stanislaus Health Services Agency in Modesto, California. If your physician found that the patient had “an infection of the middle ear accompanied by a buildup of fluid,” Johnson elaborates, “then you would code H66.001 [Acute suppurative otitis media without spontaneous rupture of ear drum, right ear].”

However, “if no otitis is found, then H92.01 [Otalgia, right ear] will be the correct diagnosis code,” according to Donelle Holle, RN, president of Peds Coding Inc., and a healthcare, coding, and reimbursement consultant in Fort Wayne, Indiana. Without a specific mention of infection, “the coder would select otalgia,” Johnson concurs.

Myth 3: When the pediatrician diagnoses the patient with terms such as “OM, left ear” or “Right ear otitis media,” a query is necessary to find the correct code.

While the codes for OM do require you know a little more information about the patient’s condition than what the diagnoses provide, a query might not be necessary.

Accurate otitis media (OM) coding, like most disease coding, hinges on your ability to recognize a number of key words, which you should be able to find in the physician’s documentation. Fortunately, OM coding only requires you to know a handful of medical terms, all of which are related to the kind of fluid the ear is discharging:

Mucoid: mucus discharge

Sanguinous: bloody discharge

Serous: thin, pale-yellow discharge

Suppurative: forming or discharging pus

This information immediately enables you to determine whether to code H65.- (Nonsuppurative otitis media) or H66.- (Suppurative and unspecified otitis media).

Understanding these terms enables you to code any kind of OM that involves a discharge of fluid other than pus as nonsuppurative. So, for chronic serous otitis media you would code H65.2-, while you would code H65.3- for chronic mucoid otitis media. And you would code H65.11- (Acute and subacute allergic otitis media (mucoid) (sanguinous) (serous)) for acute and subacute exacerbations that involve the discharge of any of these fluids.

Also: If your provider documents the cause of the OM, ICD-10 directs you to code H66.9- (Otitis media, unspecified) for cases of OM that are caused by the staphylococcal or streptococcal virus, while you would code OM due to other causes using H67.- (Otitis media in diseases classified elsewhere). The exceptions to this are B05.3 (Measles complicated by otitis media) or A38.0 (Scarlet fever with otitis media), which are both Excludes1 codes for H67.-.

However, if the doctor’s notes are vague and do not include any helpful terms to describe the patient’s condition, a query will absolutely be necessary.