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ICD-10-CM Coding for Otitis Media, UTI, and Smoking

coding for otitis media
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** This post was reviewed and updated on January 10, 2024. **

Name That Code

Question:  A 47-year-old female patient sees her physician with complaints of left ear pain. The patient was seen for a urinary tract infection three months ago that has resolved. The physician diagnoses the ear pain today as acute otitis media of the left ear and prescribes a five-day course of amoxicillin. The patient was a cigarette smoker for 20 years but quit 10 years ago. Assign for ICD-10-CM. 

Answer:

H66.92, Z87.440, Z87.891

Coding for Otitis Media, UTI, and Smoking

Before we assign the correct codes for this scenario, it is important to understand that acute otitis media is an inflammation of the middle ear that becomes infected. Although the diagnosis is commonly made in children, people of all ages may be diagnosed with the condition, which may result in recurrent ear infections. 

The documentation states that the patient is being seen for left ear pain that is subsequently diagnosed as acute otitis media in that ear. In ICD-10-CM, codes for various types of otitis media are listed in Chapter 8. Diseases of the ear and mastoid process, specifically under code range H65-H75, Diseases of the middle ear and mastoid.

Locate and Verify

Acute Otitis Media

Look in the ICD-10-CM Alphabetic Index under Otitis (acute)/media (hemorrhagic) (staphylococcal) (streptococcal) H66.9-. Looking in the Tabular Listing, we can verify the correct code as:

H66.92, Otitis media, unspecified, left ear

The unspecified code, H66.92, is appropriate here because there are no other details about the acute otitis provided other than it is in the left ear. The documentation does not indicate, for example, that the otitis media is suppurative or nonsuppurative, nor does it indicate that there is a spontaneous rupture of the eardrum. When other characteristics are present, they should be documented, in addition to left, right, or bilateral to show laterality. 

A “Use additional” note indicates a code for any associated perforated tympanic membrane should be reported with H72.-. However, there is nothing in the documentation to indicate there is a perforated tympanic membrane, so we cannot code for it.

Another “Use additional” note tells the coder to code for any identified history of tobacco dependence, among other tobacco-related use or exposure. Subsequently, we will need to look at this more in detail and discuss it below.

History of Urinary Tract Infection (UTI)

The UTI, a common infectious disease, is no longer present and does not affect the current plan of treatment. Therefore, it should not be reported as a secondary code. Instead, we need to assign a code for the history of the UTI, as instructed in the ICD-10-CM Official Guidelines for Coding and Reporting. The rule states:

“Code all documented conditions that coexist at the time of the encounter/visit and that require or affect patient care, treatment, or management. Do not code conditions that were previously treated and no longer exist. However, history codes (categories Z80-Z87) may be used as secondary codes if the historical condition or family history has an impact on current care or influences treatment.”

To find the code in the coding manual Index, look up History/personal (of)/urinary (recurrent) Z87.440. We can verify this code in the Tabular as:

Z87.440, Personal history of urinary (tract) infections

History of Cigarette Smoking

The patient “was a cigarette smoker for 20 years but quit 10 years ago.” 

A note at H66 specifies that we need to use an additional code to identify:

  • exposure to environmental tobacco smoke (Z77.22)
  • exposure to tobacco smoke in the perinatal period (P96.81)
  • history of tobacco dependence (Z87.891)
  • occupational exposure to environmental tobacco smoke (Z57.31)
  • tobacco dependence (F17.-)
  • tobacco use (Z72.0)

A history of smoking is reported with:

Z87.891, Personal history of nicotine dependence

If we were to look this code up in the Alphabetic Index, we would go to History/personal (of)/tobacco dependence, Z87.891. We must then go to the Tabular to verify that the code is correct. We can also find this code by looking up Tobacco (nicotine)/use/history in the Index. It would still take us to Z87.891.

As always, be sure to review all the Includes and Excludes2 notes before making your final code selections.

Now we have our diagnosis codes — H66.92, Z87.440, and Z87.891.

medical coder using a magnifying glass to get down to the nitty-gritty in order to for Otitis Media, UTI, and Smoking in ICD-10-CM
coding for otitis media
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6 Comments

  1. Thank you for all these great challenges! They are so helpful as I’m learning to code. I found both codes (without looking at the answer), but it was helpful to know ‘why’ I needed to chose that particular Z code. Thanks!

  2. I was wondering on some of these practices, it just asks for the ICD-10-CM code, but wouldn’t we also have to code the office visit too? Or is the office visit included in the procedure code? How can I distinguish when it’s necessary or not? Thank you.

    1. Hi Julana,

      In this particular scenario, you are only being asked to assign the ICD-10-CM codes. It is to check your knowledge of ICD-10-CM and the coding guidelines. All the coding scenarios on this site are to help medical coding students on their paths to getting their certifications.

      If you are coding for a physician’s office, you would usually assign an E/M code for the service, based on the documentation. There may also be a procedure or service performed at the time of the office visit. When that happens, it is separately reported.

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