This info will get you beyond 382.9
You can use a specific otitis media (OM) 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.
Look for Key Terms
Don't let the array of options discourage you. Most general pediatricians use only four (382.00, Acute suppurative otitis media without spontaneous rupture of eardrum; 382.01 , Acute suppurative otitis media with spontaneous rupture of eardrum; 381.01, Acute serous otitis media; and 381.10, Chronic serous otitis media, simple or unspecified) of the more than 20 OM codes.
And, although the pediatrician is ultimately responsible for the OM diagnosis, you can help educate your physician on more specific coding options and requirements if you know the key terms to look for, says Sherry Wilkerson, RHIT, CCS, CCS-P, coding and compliance manager at Esse Health in St. Louis. When the medical record doesn't contain the details that you need, ask your pediatrician for more information.
But, how do you know if you need more information? Let's look at a 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: An infant 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 pediatrician notes that the OM is acute. "Without further information, you should use 382.9, which includes acute OM," Wilkerson says. Clinically, the patient doesn't appear to have chronic OM, but the note doesn't contain much information, she says.
For instance, suppose the pediatrician also states that the child's previous two ear infections hadn't resolved with antibiotics. In this case, because clinical information indicates that the child may have chronic OM, you should ask your physician if the patient has this condition, Wilkerson says.
No hard rule defines how many ear infections a child must have before you can use a chronic diagnosis, says Nancy Bischof, MD, a private-practice pediatrician in Lexington, Ky. "I assign chronic OM when a child has an ongoing, intractable infection that wouldn't clear despite several antibiotics courses (three or more)."
Even if your pediatrician specifies that the patient has a chronic ear infection, without additional information you will still have to use the same code, 382.9, which includes acute and chronic otitis media not otherwise specified, Wilkerson says.
2. Is the Fluid Infected?
To select a more [...]