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November 23, 2009

Coding for Ear Infections
For The Record
Vol. 21 No. 22 P. 28

Otitis Media
Otitis media is inflammation that occurs when fluid becomes trapped in the middle ear and is a typical result of a common cold, the flu, or another respiratory condition that causes the Eustachian tube to swell so fluid can’t escape. It is a common condition in early childhood but rarely occurs in adults. Some common signs and symptoms of otitis media include an earache, tugging or pulling at the ear, a fever of 100 degrees or higher, irritability, restlessness, fussiness, and clear fluid in the ears.

The ICD-9-CM code assignment depends on whether the otitis media is acute or chronic and nonsuppurative or suppurative. Acute otitis media is a sudden and severe onset of a bacterial or viral middle ear infection. Chronic otitis media is an infection that continues for several weeks without clearing up and 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. Suppurative otitis media is a fluid buildup in the ear with pus formation, while nonsuppurative lacks pus formation.

The physician must document the specific type of otitis media before a code can be assigned. Assign code 382.9 if the physician does not document either acute or chronic or nonsuppurative or suppurative. Acute nonsuppurative otitis media is classified to subcategory 381.0, with the fifth-digit subclassification indicating whether it is serous (secretory), mucoid, or sanguinous. In addition, if the cause of the acute otitis media is an allergen, code 381.04, 381.05, or 381.06 is assigned. Chronic nonsuppurative otitis media is assigned to codes 381.10 to 381.3. Assign code 381.4 if the otitis media is nonsuppurative and not specified as acute or chronic.

Acute suppurative otitis media is assigned to subcategory 382.0. The fifth-digit subclassification depends on whether the eardrum is ruptured or whether the otitis media is due to another condition. Chronic suppurative otitis media is assigned to codes 382.1 to 382.3. 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 and ventilating the ear and middle ear fluid develops without a prior ear infection. There are typically no symptoms, but it can damage the ears. Antibiotics are ineffective for 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; or

• 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.

Otitis Externa
Otitis externa, which is also called acute external otitis, is an infection of the ear canal caused by bacteria in the thin layer of skin lining the canal. Because it is typically the result of excess moisture trapped in the ear, the condition is sometimes referred to as swimmer’s ear (380.12). Otitis externa may be mild in the beginning but may get worse if not treated. The symptoms that may first appear in otitis externa are itching in ear canal, slight redness of skin in ear canal, mild discomfort, or drainage of odorless fluid.

Otitis externa is classified to category 380. The specific code assignment will depend on whether the otitis externa is acute or chronic and what specific part of the ear is infected. If the otitis externa is not documented as acute or chronic, it defaults to acute. Candidal otitis externa is classified to code 112.82.

Labyrinthitis and Vestibular Neuritis
Labyrinthitis and vestibular neuritis are conditions resulting from an infection of the inner ear or vestibulocochlear nerve. Typically caused by a virus and less commonly bacteria, common symptoms include dizziness, vertigo, loss of balance, flickering of the eyes (nystagmus), and tinnitus or hearing loss.

Labyrinthitis is classified to subcategory 386.3. The fifth-digit subclassification depends on whether the labyrinthitis is documented as serous, circumscribed, suppurative, toxic, or viral. Vestibular neuritis, also called neuronitis, is assigned to code 386.12. No specific tests are available to diagnose this condition. 

Coding and sequencing for ear infections 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 Consulting Services. 3M Consulting Services is a business of 3M Health Information Systems, a supplier of coding and classification systems to more than 4,000 healthcare providers. The company and its representatives do not assume any responsibility for reimbursement decisions or claims denials made by providers or payers as the result of the misuse of this coding information. More information about 3M Health Information Systems is available at www.3mhis.com or by calling 800-367-2447.