Primary Care Coding Alert

Move beyond 382.9 to obtain the reimbursement you deserve

When you report otitis media (OM), use a specific diagnosis to better support your E/M code if you know the OM type and related symptoms, such as allergic, suppurative, serous, mucoid and sanguinous.

"I believe that many physicians do not realize that the ICD-9 codes for ear infections are as specific as they are, therefore when they are documenting the medical record, they merely state the diagnosis as 'ear infection,' " says Kathy Pride, CPC, CCS-P, a coding consultant for QuadraMed in Port St. Lucie, Fla.

Search for Those Key Terms

Don't let the array of options discourage you. Most family physicians (FPs) use only four of the more than 20 OM codes: 382.00, Acute suppurative otitis media without spontaneous rupture of ear drum; 382.01, Acute suppurative otitis media with spontaneous rupture of ear drum; 381.01, Acute serous otitis media; and 381.10, Chronic serous otitis media, simple or unspecified.

Expert tip: When you know that the physician will see a patient for an ear infection, add a document to the patient's medical record that is a checklist of the ear infection terms, such as chronic, acute, suppurative, nonsuppurative, mucoid and with anterior perforation, Pride says. "Then the physician can check off which terms apply to the patient, and the coder can use the check list to select the diagnosis." (See chart below.)

And although the FP is ultimately responsible for selecting the OM diagnosis, you can help educate your physician regarding more specific coding options and requirements if you can identify the key terms. When the medical record doesn't contain the details that you need, ask your FP for more information.

"Remember, each digit provides important and specific information, and you want to select the most appropriate ICD-9 code possible because you are establishing the need or medical necessity for the patient's visit and treatment by your physicians," says Judy Richardson, MSA, RN, CCS-P, senior coding consultant with Hill & Associates in Wilmington, N.C.

But how do you know if you need more information? Look at the following sample note and see how omitting key details will force you to use 382.9 (Unspecified otitis media) unless you know the right questions to ask.

The problem: A child presents for a suspected third episode of acute OM within the past two to three months. Coding experts recommend that you answer these four questions to find the correct OM diagnosis.

1. Is the Infection Short- or Long-Term?

To select the OM code, you should first determine whether the patient has acute (brief) or chronic (prolonged) OM.

In the above scenario, the FP documents acute OM. Without further information, you should use 382.9, which includes acute OM. Clinically, the patient doesn't appear to have chronic OM, but the note doesn't contain enough information to select a different diagnosis.

For instance, suppose the FP also states that the child's previous two ear infections didn't resolve with antibiotics. In this case, because clinical information indicates that the child may have chronic OM, you should ask your physician if the patient has this condition.

"No hard rule defines how many ear infections a child must have before you can use a chronic diagnosis," Richardson says. "Generally, you should assign chronic OM when a child has an ongoing, intractable infection that wouldn't clear despite several antibiotics courses (three or more)."

Even if your FP specifies that the patient has a chronic ear infection, without additional information you will still have to use the same code, 382.9, which includes acute and chronic otitis media not otherwise specified.

2. Is There Pus in the Middle-Ear Fluid?

To select a more specific code, you need to know whe-ther the middle-ear cavity's fluid is infected. After zeroing in on acute OM in the above example, you should look in the exam note for more information on the fluid's type.

Suppose the exam note states that upon otoscopic exam of the tympanic membrane, the FP found no infection in the middle-ear cavity's fluid.

In this case, you should use a nonsuppurative OM code from the 381.x series (Nonsuppurative otitis media and Eustachian tube disorders). Alternatively, if the FP notes that the fluid contains pus, go to the 382.x series for a suppurative diagnosis.

3. What Are the OM-Related Symptoms?

To arrive at the fourth- or fifth-digit code within the 381.x and 382.x series, you should find the code that combines the relevant OM conditions. These details include noting whether or not the fluid is serous (thin or thick), sanguinous (with blood), or mucoid (with mucous).

And, if an allergy triggered the patient's ear infection, you should use an allergic diagnosis, such as 381.04 (Acute allergic serous otitis media). If the patient has suppurative OM, you must also know details about any eardrum damage.

4. Which Code Identifies the Combined Conditions?

Armed with what the terms mean and what to look for in OM notes, your final step is to find the code that combines the relevant findings. 

To test your knowledge, read the following exam note and use the chart to arrive at the ICD-9 code that contains the correct OM combination.

Additional details: The FP notes that she is seeing an infant for a new ear infection. In the exam notes, she states the following findings: yellow and/or red (erythema) color, bulging contour, loss of ossicular landmarks and decreased mobility of membrane, effusion with pus.

Answer: You should report 382.00 (Acute suppurative otitis media without spontaneous rupture of ear drum). The "new" indication clearly identifies the OM as acute. And you can tell that the OM is suppurative from the "pus" notation. The FP doesn't mention eardrum damage. The additional details allow you to use 382.00, rather than the original nonspecific 382.9 diagnosis.