M19.012 - Primary osteoarthritis, left shoulder

Clinical Definition

Otitis media is inflammation or infection of the middle ear space, typically presenting with ear pain, decreased hearing, and possible fever. This can be acute or chronic, and may be associated with effusion (fluid buildup).

Documentation Requirements

• Must specify:

  • Acuity (acute vs. chronic)

  • Laterality (left, right, or bilateral)

  • Presence/absence of tympanic membrane rupture

  • Presence/absence of otorrhea (drainage)

  • Whether effusion is present

  • Any underlying cause if known

• Timing:

  • Acute: <3 weeks duration

  • Chronic: ≥3 months duration

Common Synonyms

• Middle ear infection

• Ear infection

• Fluid in ears

• Running ears (if drainage present)

• "My kid is pulling at their ears"

Coding Conflicts

Excludes1:

• Otitic barotrauma (T70.0)

• Otitis externa (H60.-)

Excludes2:

• Myringitis without otitis media

• Eustachian tube disorders

Scribing.io Automation

Our AI system automatically identifies:

• Keywords indicating location ("middle ear," "tympanic")

• Duration descriptors ("3 weeks," "chronic")

• Side-specific terms ("left ear," "bilateral")

• Associated symptoms ("drainage," "effusion")

• Temporal patterns ("recurrent," "persistent")

The system flags missing elements and prompts for additional specificity needed for accurate coding.