Pediatric Coding Alert

Question: Regarding November 2003's Pediatric Coding Alert article "Case Study: 4 Answers You Need When Coding OM," how does breaking down the otitis media (OM) diagnosis to the detail described in the story benefit a general pediatric practice? Most pediatricians do not document enough to give that specific diagnosis for an E/M code. If no real benefit exists for using a more specific ICD-9 code, why should I go back to the physician for additional documentation?

Michigan Subscriber

Answer: First, you shouldn't assume that simply using a more specific OM code, such as 382.00 (Acute suppurative otitis media without spontaneous rupture of ear drum), rather than a nonspecific OM diagnosis (382.9, Unspecified otitis media) will justify using a higher-level E/M code (for instance, 99214-99215, Office visit for the evaluation and management of an established patient ...). You should always select the appropriate level of E/M service based on the driving factor of the documented level of risk and medical decision-making. Even though the ICD-9 code shouldn't directly tie to the E/M code, some payers will reject high-level E/Ms with certain lower-complexity diagnoses.
 
If you aren't receiving denials for using the nonspecific OM code, your pediatrician should still provide the extra information. ICD-9 coding guidelines require coding to the highest specificity possible.
 
And fully documenting the OM type may help protect your pediatrician against malpractice suits. Documenting the patient's specific OM will support the different approaches the pediatrician takes for various OM diagnoses. For instance, serous OM (such as 381.01, Acute serous otitis media) doesn't typically require antibiotics. But suppurative OM (for instance, 382.00) usually does. For tracking purposes, proper OM coding will also allow a better analysis of how a patient's condition is progressing.
 
Doing the right thing - coding OM properly - doesn't have to be that time-consuming. Basically, you need to know if:
  the infection is acute or chronic
  an ear perforation exists
  the fluid contains pus.

Tip: Some pediatricians use simple acronyms to indicate the relevant OM. In a general pediatrician's office, you only need to use four notations to cover the most common pediatric OM codes. To avoid going back to your pediatrician for more information, try encouraging him or her to use the following abbreviations:
  SOM ([Acute] serous otitis media) - 381.01, Acute serous.
  CSOM (Chronic serous otitis media) - 381.10, Chronic serous otitis media, simple or unspecified.
  ASOM (Acute suppurative otitis media) - 382.00, Acute suppurative OM  without spontaneous rupture of ear drum. Even though this acronym could also stand for serous, a simple look to see whether the notes state pus will confirm suppurative (purulent).
  ASOM w/perf (Acute suppurative otitis media with eardrum perforation) - 382.01, Acute suppurative OM with spontaneous rupture of ear drum.

- Answers to You Be the Coder and Reader Questions provided by Barbara J. Cobuzzi, CPC, CPC-H, CHBME, president of Cash Flow Solutions Inc., a premier medical billing company in Lakewood, N.J.; Jeffrey Linzer Sr., MD, FAAP, assistant professor of pediatrics for the division of emergency medicine at Emory University School of Medicine in Atlanta; and Charles A. Scott, MD, FAAP, a pediatrician at Medford Pediatric & Adolescent Medicine PA in Medford, N.J.