Learn Key Terms for Accurate Otitis Media Coding
Question: I’m relatively new to coding. When my pediatrician diagnoses a patient using terms like, “OM, left ear” or “Right ear otitis media,” should I just query them to find the correct code? Minnesota Subscriber Answer: First, you’ll need a little more information than the diagnosis alone to assign the correct otitis media (OM) code, but that information is often available in the medical record without the need for a query. Accurate OM coding relies on identifying a few important terms within the provider’s documentation, all of which relate to the type of ear discharge the patient is presenting with at the appointment. Here’s a look at some key terms you might see in the documentation: This information will help you determine whether to look for a diagnosis code in the H65.- (Nonsuppurative otitis media) or H66.- (Suppurative and unspecified otitis media) category. Understanding these terms enables you to code any kind of OM that involves a discharge of fluid other than pus as nonsuppurative. So, for chronic serous OM you would look to codes in the H65.2- (Chronic serous otitis media) subcategory, while you would select a code from H65.3- (Chronic mucoid otitis media) for chronic mucoid otitis media. Also, you would choose a code from the H65.11- (Acute and subacute allergic otitis media (mucoid) (sanguinous) (serous)) subcategory for acute and subacute exacerbations that involve the discharge of any of these fluids. If your provider documents the cause of the OM, ICD-10-CM directs you to subcategory H66.9- (Otitis media, unspecified) for cases of OM that are caused by the staphylococcal or streptococcal virus, while you would code OM due to other causes using a code from H67.- (Otitis media in diseases classified elsewhere). The exceptions to this are B05.3 (Measles complicated by otitis media) or A38.0 (Scarlet fever with otitis media), which are both Excludes1 codes for H67.-. However, if the physician’s notes are too vague to identify the patient’s specific condition, a provider query will be needed. Lindsey Bush, BA, MA, CPC, Production Editor, AAPC
