Documentation Detective

Documentation Detective

 

AUDIOLOGY

Does your documentation specify:

Otitis:

·         Media?  Externa?

·         Suppurative?   Non-Suppurative?

·         Infective?    Non-Infective?

·         Tobacco Smoke exposure?

·         Acute?   Chronic?

·         Recurrent?

·         With/without spontaneous rupture of eardrum?

·         Laterality?

·         Hearing Loss? (Yes/No)   If yes – what type? (conductive, sensorineural and/or mixed loss)?  

·         Hearing loss-related speech delay?  Document linkage.

…(e.g., speech and language development delay due to hearing loss)  

 

IF there is Hearing Loss, describe hearing ability on both sides (e.g., conductive hearing loss; unilateral, right ear, with unrestricted hearing on contralateral side)

Documentation for all ear and mastoid process conditions should include:

1.      Ear(s) involved (right, left, or bilateral)

2.      Acuity of condition (acute or chronic)

3.      Whether condition was due to an infection, chemical exposure, or external injury.

 

CODING EXAMPLES:

 

DOCUMENTED:  ……….………………………………………    REQUIRES:

Malignant otitis externa bilateral ……………………… ONE CODE – Otitis Externa, Bilateral

Acute Serous Otitis Media|recurrent; left ear..….. ONE CODE – Media, non-suppurative, recurrent, L. ear

Swimmer’s ear (left ear) …………………………………….. ONE CODE – Swimmer’s ear, left ear