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 [...]