Otolaryngology Coding Alert

This info will get you beyond nonspecific code 382.9 You can use a specific otitis media (OM) 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. Look for Key Terms Although your otolaryngologist is ultimately responsible for the OM diagnosis, you can help educate him or her on more specific coding options and requirements if you know the key terms to look for, says Sherry Wilkerson, RHIT, CCS, CCS-P, coding and compliance manager at Esse Health in St. Louis. When the medical record doesn't contain the details you need, ask your otolaryngologist for more information.
 
But how do you know if you need more information? Take a look at a sample note that demonstrates how omitting key details will force you to use 382.9 (Unspecified otitis media) unless you know the right questions to ask.
 
The problem: An otolaryngologist notes that she is seeing a child on a pediatrician's request regarding a suspected fourth episode of acute OM within the past six 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 otolaryngologist notes that the OM is acute. "Without further information, you should use 382.9 (Suppurative and unspecified otitis media; unspecified otitis media), which includes acute OM," Wilkerson says. Clinically, the patient doesn't appear to have chronic OM, but the note doesn't contain much information, she says.
 
For instance, suppose the otolaryngologist also states that the child's previous two ear infections hadn't resolved 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, Wilkerson says.
 
No hard rule defines how many ear infections a child must have before you use a chronic diagnosis, says Nancy Bischof, MD, in Lexington, Ky. "I 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 otolaryngologist specifies that the patient has a chronic ear infection, without additional information you will still have to use 382.9, which includes acute and chronic otitis media not otherwise specified, Wilkerson says. 2. Is the Fluid Infected? To select a more specific code, you need to know whether 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, Wilkerson says.
 
Suppose the exam note states that upon otoscopic exam of [...]