June 01, 2015
Area(s) of Interest: Payor Issues and Reimbursement Practice Management
CPR’s “Coding Corner” focuses on coding, compliance and documentation issues relating specifically to physician billing. This month’s tip comes from Peggy Silley, the Director of ICD-10 Development and Training for AAPC, a training and credentialing association for the business side of health care.
Ear infections are a common condition, treated by a variety of physicians including primary care, urgent care, emergency departments, and ear, nose and throat specialists. Although diagnosis codes for otitis media (OM) in ICD-10-CM differ greatly than those in ICD-9-CM, the required concepts are very similar.
Good clinical documentation should include the following concepts:
- The type of otitis media, including infectious, allergic, tubotympanic, atticoantral or other
- Any manifestations, such as serous, mucoid, suppurative, or non-suppurative
- Any rupture of the tympanic membrane
- The infectious agent, if known
- Time parameters of acute, subacute, chronic, or acute recurrent should be documented. According to the American Academy of Otolaryngology-Head and Neck Surgery, the following criteria are used to determine time parameters.
- Acute is acute onset
- Persistent is a relapse within one month of treatment
- Recurrent is three or more episodes of acute otitis media within six to 18 months
- Chronic is persistent and recurrent (three or more episodes within six to 18 months and relapse within one month of treatment)
- Acute recurrent is usually defined as three or more distinct, documented episodes of acute OM within six months, or four or more episodes within 12 months.
- Always documented laterality (e.g., left or right). This is true not just with otitis media, but with any condition that has a laterality issue.
- Tobacco dependence (F17.-)
- Tobacco use (Z72.0)
- History of tobacco use (Z87.891)
- Exposure to environmental tobacco smoke (Z77.22)
- Occupational exposure to environmental tobacco smoke (Z57.31)
- Exposure to tobacco smoke in the perinatal period (P96.81)
- Tobacco use (smoking) during pregnancy, childbirth, and the puerperium (O99.33)