Coding for Otitis Media
For The Record
Vol. 18 No. 3 P. 47

Otitis media is inflammation of the middle ear. It is caused by fluid trapped in the middle ear, causing the area to become inflamed and infected. Otitis media typically occurs after a common cold, flu, or other respiratory condition that makes the Eustachian tube so swollen that fluid cannot escape. It can also be caused by allergies or enlarged adenoids. Otitis media is the most common diagnosis in preschoolers. By the age of 6, 75% of all children will have had at least one episode of otitis media.

Signs and Symptoms
Common signs and symptoms of otitis media include the following:

• earache;

• tugging or pulling at the ear;

• fever;

• irritability, restlessness, and fussiness;

• nasal discharge;

• diminished appetite;

• crying when lying down;

• red and bulging eardrum;

• hearing problems;

• ear drainage; and

• nausea, vomiting, and diarrhea.

ICD-9-CM Coding
ICD-9-CM code assignment will depend on whether the otitis media is acute or chronic, nonsuppurative or suppurative. Acute otitis media is a sudden and severe onset of a bacterial or viral infection of the middle ear. Chronic otitis media is an infection that continues for several weeks without clearing up. The condition may be due to persistent fluid behind the eardrum from repeated middle ear infections, such that the fluid does not go away on its own as in most cases of otitis media.

Suppurative otitis media is a fluid buildup in the ear with pus formation, and nonsuppurative is without pus formation.

The physician must document the specific type of otitis media before a code can be assigned. If the physician documents neither acute or chronic, nonsuppurative or suppurative, assign code 382.9. Acute nonsuppurative otitis media is classified to code 381.0x, with the fifth digit of the code assignment indicating whether it is serous (secretory), mucoid, or sanguinous. In addition, if the cause of the acute otitis media is an allergen, it will be assigned to code 381.04, 381.05 or 381.06. Chronic nonsuppurative otitis media is assigned to codes 381.10-381.3. Assign code 381.4 if the otitis media is without pus formation (nonsuppurative) and not specified as acute or chronic.

Acute suppurative otitis media is assigned to code 382.0x. The fifth-digit subclassification depends on whether the eardrum is ruptured or whether the otitis media is due to another condition. For example, if the acute suppurative otitis media is due to influenza, code 487.8 would be sequenced first followed by code 382.02. If postmeasles otitis is documented, code 055.2 is assigned with no additional code from category 381 or 382.

A ruptured eardrum with acute suppurative otitis media is classified to code 382.01. Code 382.00 is assigned if the acute suppurative otitis media is not further specified. Chronic suppurative otitis media is assigned to codes 382.1 to 382.3. The specific code assignment for chronic suppurative otitis media depends on whether the tubotympanic or atticoantral portion of the middle ear was involved. If the suppurative otitis media is not further specified, assign code 382.4.

Otitis media with effusion is the presence of middle ear fluid that may last for several weeks even after the acute infection has passed. This can also occur when the Eustachian tube is not functioning to ventilate the ear and the middle ear fluid develops without a prior ear infection. There are typically no symptoms, but it can damage the ears. Antibiotics are not effective in treating otitis media with effusion. The code assignment for otitis media with effusion will depend on whether it is acute or chronic:

• 381.00 — acute otitis media with effusion;

• 381.3 — chronic otitis media with effusion; and

• 381.4 — otitis media with effusion not specified as acute or chronic.

If the causative organism is specified, a code from category 041 may be assigned as an additional code with otitis media.

Treatment
The first line of treatment for otitis media is antibiotics. Antibiotics will kill the invading bacteria if the otitis media is caused by bacteria. If the otitis media is caused by a viral infection, the physician can only relieve the symptoms since viruses do not respond to antibiotics.

If the otitis media fails to respond to the antibiotics, is chronic, or recurs frequently, a myringotomy with tube insertion may be needed. A myringotomy is a surgical incision in the eardrum to release the fluid from the middle ear. Ventilation tubes (also called tympanostomy) may need to be inserted to keep the Eustachian tube open, preventing fluid accumulation. The tubes will stay in for six months to three years and then fall out on their own.

Myringotomy without tube insertion is assigned to code 20.09. For myringotomy with tube insertion (tympanostomy), assign code 20.01. If the tubes have to be removed, assign code 20.1.

Complications
If otitis media is left untreated, it is possible that serious complications may arise. Otitis media is the most common cause of hearing loss (389.x) in children. If the otitis media is treated promptly and effectively, hearing can almost always be restored to normal.

Mastoiditis (383.x) is an infection of the bony air cells in the mastoid bone located just behind the ear. It causes bone destruction but is rarely seen today because of the use of antibiotics to treat ear infections.

Another complication of otitis media is meningitis. Meningitis is an infection of the membranes, or meninges, that cover the brain and spinal cord. Meningitis is almost always caused by bacterial infections in other parts of the body (ie, ears) that can spread to the brain or spinal cord via the bloodstream.

Other complications of otitis media include Meniere’s disease (386.0x), labrynthitis (386.3x), facial nerve paralysis (351.0), and petrositis (383.2x).

Coding and sequencing for otitis media are dependent on the physician documentation in the medical record and application of the Official Coding Guidelines for inpatient care. Also, use specific AHA Coding Clinic for ICD-9-CM and American Medical Association CPT Assistant references to ensure complete and accurate coding.

— This information was prepared by Audrey Howard, RHIA, of 3M Health Information Systems (800-367-2447), a supplier of coding and classification systems to nearly 5,000 healthcare providers. The company and its representatives do not assume any responsibility for reimbursement decisions or claims denials made by providers or payors as the result of the misuse of this coding information.

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