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Otitis Media

Chief Complaint:

The patient is a 3 year old male brought in by his mother. He has had a low grade fever of 100.5 for 3 days. He is complaining that his ears hurt with difficulty sleeping. He also has a non-productive cough that started yesterday. Examination of both ears reveals significant redness and fluid in both middle ears with no apparent involvement of the eardrum or tympanic membrane. Further examination of the patient’s breathing and other manifestations indicates an upper respiratory infection. The patient’s parents are chronic heavy smokers and the child is exposed to second hand smoke in the home environment

History:

  • The patient has recurrent episodes of middle ear infections.

Assessment:

  • Acute recurrent serous otitis media
  • Upper respiratory infection (presumed of viral origin)
  • Chronis secondary smoke exposure

Documentation Tips

  • Reporting otitis media in ICD-10 allows for the differentiation between an acute episode versus an acute episode of a recurrent infection.
  • Guidelines of otitis media coding state that if there is a smoking or smoking exposure history in the patient environment, and additional code should be used to indicate that exposure.

Comparison of Current ICD-9 Code and Illustrative ICD-10 Codes

ICD-9-CM

381.01 Acute serous otitis media

465.9 Acute upper respiratory infections of unspecified site

ICD-10-CM

H65.06 Acute serous otitis media, recurrent, bilateral

J06.9 Acute upper respiratory infection, unspecified

Z77.22 Contact with and (suspected) exposure to environmental tobacco smoke (acute) (chronic)