Pediatric Coding Alert

Understanding clinical terms, laterality, and instructions will steer you in the right direction.

The otitis media (OM) codes can be a real test of your clinical and coding understanding. But these four ICD-10 hacks will help you quickly hone in on the correct code.

And don’t forget to stay tuned to the end, when you can put your newfound knowledge to the test by coding a classic OM case study.

Hack 1: Learn These Terms to Quickly Narrow Down Code Choices

Nonsuppurative vs. suppurative: Simply put, if your pediatrician documents that one or both of the patient’s ears is oozing pus, you will look to using a code from H66.- (Suppurative and unspecified otitis media).

A similar term to suppurative is purulent. If you see this term in your pediatrician’s documentation, you can not only go straight to the H66.- codes, but also straight to H66.4- (Suppurative otitis media, unspecified) because purulent otitis media NOS is a synonym for the code.

Conversely, you will code noninfected ear conditions with H65.- (Nonsuppurative otitis media). Nonsuppurative ear conditions also feature secretions, which are either serous, mucoid, or sanguinous. Serous fluid is a thin, clear or yellowish fluid, whereas mucoid fluid, as its name implies, is a thicker, mucus discharge. Sanguinous fluid is a reddish discharge indicating blood is present in the fluid.

Fortunately, for ICD-10 purposes, the terms are subordinate to your provider’s documentation of OM severity. For acute serous OM, you’ll use H65.0- (Acute serous otitis media); and for acute mucoid and sanguinous OM, you’ll use H65.19- (Other acute nonsuppurative otitis media).

Hack 2: Convert These Terms to ICD-10 Codes

You may see your pediatrician document otitis media with effusion (OME), and chronic otitis media with effusion (COME). To find the precise codes for these common conditions, you’ll need to go back to the ICD-10 index.

OME occurs when the acute otitis media (AOM) is over, but fluid still exists and is visible behind the ear drum. The condition is also known as serous OM. The alphabetic index tells you look to otitis, media, nonsuppurative to find otitis (acute) with effusion, which leads you to H65.9- (Unspecified nonsuppurative otitis media).

COME occurs when the middle ear fluid remains over time without an infection present in the patient. For this condition, the index tells you go to otitis, media, nonsuppurative, chronic, which leads you to use H65.49- (Other chronic nonsuppurative otitis media). Here, you’ll see the synonym “chronic otitis media with effusion (nonpurulent),” confirming you have the right code for the condition.

Hack 3: Pay Attention to Laterality

All the OM codes specify the laterality of condition. That means you “need to stipulate which ear — left, right, or bilateral — has the condition. To do less would not be coding to the highest level of specificity,” says Melanie Witt, RN, CPC, MA, an independent coding expert based in Guadalupita, New Mexico.

To do this, you will have to work closely with your pediatrician to make sure laterality is documented in the patient’s record and avoid using any of the unspecified ear OM codes whenever possible.

Hack 4: Read the Instructions for the H60-H95 Codes

Hiding in plain sight at the beginning of the H60-H95 (Diseases of the ear and mastoid process) codes is an Excludes2 note for the whole category instructing you to use a code from R00-R94 (Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified), which can be separately reported with an H60-H95 code when appropriate.

Remember: An Excludes2 note means a specific condition is “not included here.” In other words, a condition identified by an Excludes2 note is medically related to the main condition but can occur independently of that condition. It is separately reportable under a different ICD-10 code and not included under the ICD-10 code under which the Excludes2 note appears.

In addition, ICD-10 guideline I.C.20.a.1. tells you that “an external cause code may be used with any code in the range of A00.0-T88.9, Z00-Z99, classification that represents a health condition due to an external cause.” The external cause codes are “valid for use with such things as infections or diseases due to an external source, and other health conditions.” This is reinforced by the Use additional code instructions accompanying the H65 and H66 codes, which tell you to code the following when applicable:

• exposure to environmental tobacco smoke (Z77.22)
• exposure to tobacco smoke in the perinatal period (P96.81)
• history of tobacco dependence (Z87.891)
• occupational exposure to environmental tobacco smoke (Z57.31)
• tobacco dependence (F17.-)
• tobacco use (Z72.0).

Can You Code This Case?

Your pediatrician sees an 8-month-old female patient who has been tugging at her ears for two days. On examination, the pediatrician notes pus is coming out of the child’s left ear. The child’s ear drum is intact, but the child is running a fever. This is the first time the child has seen the pediatrician for this condition. The child’s mother has a history of smoking.

The presence of pus in the child’s ear indicates the ear is infected, sending you to the H66.- codes. As the infection is recent, that tells you the condition is acute, enabling you to further narrow down the code choice to H66.0-.

As the ear drum is not ruptured, the infection is in the left ear, and the pediatrician has not reported that the condition is recurrent, you can then go ahead and code H66.002 (Acute suppurative otitis media without spontaneous rupture of ear drum, left ear).

You’ll also need to document the child’s fever with R50.9 (Fever, unspecified) per the H60-H95 Excludes2 note. And as the child has been exposed to her mother’s smoking, you should also use an additional code: Z77.22 (Contact with and (suspected) exposure to environmental tobacco smoke (acute) (chronic)).