Pediatric Coding Alert

Question: A patient came in recently with a bad ear infection. Our pediatrician documented the condition as “purulent” and wrote that their ears were oozing pus. This seems like a pretty severe case, so should I code using H65.0-?

Indiana Subscriber

Answer: You’re right that this sounds like a pretty severe infection. However, H65.0- (Acute serous otitis media) is not the correct code to report. Here’s why:

Serous otitis media refers to a nonsuppurative ear condition. Nonsuppurative conditions lack pus formation, whereas suppurative conditions are characterized by pus formation. Also, a serous secretion is thin, clear, or yellowish fluid, which does not describe pus.

Additionally, the pediatrician described the patient’s condition as purulent. That is a term similar enough to suppurative that you can always go straight to H66.4- (Suppurative otitis media, unspecified) when the doctor uses it to describe otitis media (OM).