Need help with E/M for COM


Local Chapter Officer
Saratoga Springs, UT
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Hi I have a question for you all re: chronic otitis media and placement if tubes.

I have a note that I'm leveling for a 2 new patients.

Patient A has c/o chronic otitis media (5-6 infections in 12 months). This patient wishes to wait before considering a BMT. For the MDM I circled Moderate for the COM with exacerbation/progression.

This would give the patient a 99204 charge.

Patient B is the same scenario, however they want to proceed with a BMT. A BMT is a minor surgery and is a low MDM. Ordinarily I would assign a low MDM to this patient b/c even though he has an exacerbation of COM the fix for this is a minor procedure. This would give the patient a 99203 charge.

I'm questioning this b/c two patients with the same complaint should be getting the same charge whether or not one decides to have the surgery and the other decides to wait and see.

What are your thoughts? How would you level these two patients?

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Personally I'd focus primarily on the condition and its severity in this case. In the table of risk under High it includes any chronic illness that poses a threat to life or bodily function. From the Merek Manual:

"Persistent infection can destroy parts of the ossicles—the small bones in the middle ear that connect the eardrum to the inner ear and conduct sounds from the outer ear to the inner ear—causing conductive hearing loss (hearing loss that occurs when sound is blocked from reaching the sensory structures in the inner ear).

Some people with chronic otitis media develop a cholesteatoma in the middle ear. A cholesteatoma is a noncancerous (benign) growth of white skinlike material. A cholesteatoma, which destroys bone, greatly increases the likelihood of other serious complications such as inflammation of the inner ear, facial paralysis, and brain infections."

I'd say chronic otitis media at that frequency certainly qualifies as a potential threat to bodily function. In your case (if all else is equal between the two patients), both patients could face permanent damage as mentioned; in fact, I'd go as far to say that the patient NOT getting the procedure is running a higher risk. That's my two cents anyway.


True Blue
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The guidance usually given for risk selection in E&M coding is that the level of risk should be reflected in the documentation and coders shouldn't rely on their own interpretation or assessment of the patient's condition, though that's often easier said than done. In a case like this, I would not assess a high level of risk for a diagnosis such as COM unless the provider has specifically documented that the patient is at real risk for permanent loss of hearing. Keep in mind also that 99204 requires a medically necessary comprehensive history and exam - a comprehensive physical exam would be unusual for treatment of an otherwise healthy individual with otitis media.

COM is a pretty common condition and in my experience with ENT, would not be considered by providers to be high risk for most patients. Also, for the ENT specialty, 99204 and 99205 are relatively rare (you can run a comparison for the specialty on the E/M Analyzer on this site) and are more often seen billed for complex ENT illnesses such as cancers/tumors of the mouth or head which require complex management and/or diagnostic testing. If you're regularly coding your new OM patients with 99204, you're likely to show up as an outlier for your specialty which could invite payer audits.