Created Aug 2017
Reviewed Dec 2019
Patient is admitted with ear pain for one day, diagnosed as otitis externa, swabs were done which grew Pseudomonas aeruginosa, patient was given oral antibiotics. Otitis externa was not mentioned as being invasive, or complicated. The Pseudomonas was not mentioned in the clinical record, only on the laboratory result.
In the pathway, otitis externa has an entry for Pseudomonas aeruginosa, which goes to H60.2 Malignant otitis externa. Research indicates malignant otitis externa is a relatively rare invasive form of otitis externa. Therefore, the question is, would the correct code assignment be H60.2 Malignant otitis externa or H60.3 Other infective otitis externa with B96.5 Pseudomonas aeruginosa or something else?
As per the ICD-10-AM Alphabetic Index Pseudomonas aeruginosa and Infective are essential modifiers. Therefore, as per the classification principles these essential modifiers must be documented in the clinical record.
In this case, the clinician should be consulted to confirm the diagnosis. However, where it is not possible to obtain further clarification from the clinician the most appropriate codes to assign are H60.9 Otitis externa, unspecified and B96.5 Pseudomonas (aeruginosa) as the cause of diseases classified to other chapters.