Primary Care Coding Alert

With more than 24 codes to choose from (381.00-382.9), coding an otitis media diagnoses can be a real earful. To select the correct code, you'll need to 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.

Typical Otitis Scenarios

FPs often see five kinds of otitis media cases:

1. Ear infection discovered at a well visit: A baby with no ear discomfort comes in for a well visit, and an ear infection is discovered. Code separately for the ear infection, using an office visit (99211-99215) with modifier -25 (Significant, separately identifiable E/M services 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. Link the otitis media diagnosis, usually 381.01 (Nonsup-purative otitis media and Eustachian tube disorders; acute serous otitis media) or 382.00 (Acute suppurative otitis media without spontaneous rupture of ear drum), to the office visit, and link V20.2 (Routine infant or child health check) to the preventive medicine service.

Usually, the child gets an antibiotic. "It is impossible to tell if the infection is bacteria or a virus without getting a sample of the fluid behind the eardrum," says Daniel S. Fick, MD, medical director for the Joint Office of Compliance at the University of Iowa Health Care in Iowa City. "Obviously docs are not going to poke holes in the tympanic membrane (eardrum) to find out, so most kids get antibiotics."

2. Minor discomfort or low fever: A baby with minor discomfort or a low fever is brought in, and the infection is discovered early. The ear infection discovered early on by an FP is most likely 382.00. Code an office visit (99211-99215). "All new infections are called acute, and then if it lasts more than a couple weeks it's called chronic," Fick says. "It is often a subjective call by the physician when to call it chronic."

3. High fever and advanced infection: A baby presents with a high fever that is caused by an advanced and painful ear 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, help substantiate 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 a cold: A baby who is recovering or just recovered from a cold has a slight fever or fussiness. 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. Code an office visit (99211-99215).

5. Recurrent infections with surgical evaluation needed: A toddler has had recurrent otitis media and now needs an evaluation by an otolaryngologist (ENT) for possible surgery.

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, the FP would refer the child to an ENT for possible tubes.

According to Fick, there are no hard and fast rules for when to refer, but he usually uses more than three in six months or four in a year. This visit will probably require more time because the parent will need an explanation and reassurance. If the discussion is long and takes up more than 50 percent of the encounter time, you may be able to code a higher level of service based on time than you otherwise would based on history, exam and medical decision-making, 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 (Acute suppurative otitis media in diseases classified elsewhere) 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.

Coding the 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.