Wiki ICD-10 Otits Media Coding

[Meridith618]

I am in need of some help. When ICD-10 coding acute non-suppurative vs acute suppurative otitis media in the physician's office, does the physician need to document suppurative or non-suppurative, and if it is NOT documented, is the non-suppurative the default diagnosis? I am auditing ear charts and many doctors are not documenting this info. Are there key words I should look for while auditing these charts? Thank you in advance for your help and wisdom!

 

[Cynthia Hughes]

Be sure to look for other sub-terms that physicians use such as serous or purulent but if the documentation is only acute otitis media, codes in category H66.9- are the default (otitis media, unspecified).