Otolaryngology Coding Alert

Question: What diagnosis code should be used when a patient returns six months to one year after myringotomy surgery for a tube check? All the physician has written in the chart is patent tubes in place.

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Answer: Because all the otolaryngologist wrote was patent tubes in place, there is no diagnosis, says Teresa Thompson, CPC, an independent otolaryngology coding and reimbursement specialist in Sequim, Wash. When the coder sees a claim without a documented diagnosis, he or she should remind the otolaryngologist that no diagnosis code was written down and that the claim likely will not get paid without one.
The tubes likely were inserted for a condition such as dysfunction of the eustachian tube (381.81) or acute serous otitis media (381.01). Either of these codes, if appropriate, could be used as the diagnosis code to justify the visit, Thompson says.

Although there is a V code in the ICD-9 manual for follow-up after surgery (V67), using it as a primary diagnosis is likely to result in a denial, she adds.