What is the initial step for an adult patient with unspecified ear problems requiring referral to an Ear, Nose, and Throat (ENT) specialist?

ICD-10 Coding for Ear Problems Requiring ENT Referral

For adult patients with unspecified ear problems requiring ENT referral, use ICD-10 code H92.9 (Otalgia, unspecified) for ear pain, H91.90 (Unspecified hearing loss, unspecified ear) for hearing concerns, or H93.90 (Unspecified disorder of ear, unspecified ear) for general ear complaints when a more specific diagnosis cannot be established at the initial evaluation.

Initial Clinical Assessment Before Referral

Before coding and referring to ENT, perform a targeted evaluation to determine if specialist consultation is truly necessary:

Essential History Elements

• Onset and duration of symptoms (acute vs. chronic presentation) 1
• Laterality (unilateral symptoms warrant higher concern for serious pathology) 1, 2
• Associated symptoms including hearing loss, vertigo, otalgia, otorrhea, tinnitus, or neurological symptoms 3, 1
• Pattern and quality of symptoms (fluctuating vs. constant, character of pain or discharge) 1

Physical Examination Requirements

• Otoscopic examination to identify cerumen impaction, tympanic membrane abnormalities, or middle ear pathology 1, 4
• Tragal tenderness assessment (hallmark sign of acute otitis externa) 3
• Cranial nerve examination, especially CN VIII for hearing 1
• Auscultation for bruits if pulsatile symptoms reported 1

Specific ICD-10 Codes Based on Clinical Findings

When More Specific Diagnosis Is Possible

• H60.90 - Unspecified otitis externa, unspecified ear (if canal inflammation present) 3
• H66.90 - Otitis media, unspecified, unspecified ear (if middle ear involvement suspected) 3
• H92.0 - Otalgia (ear pain), with laterality specified when possible 3
• H61.20 - Impacted cerumen, unspecified ear (common cause requiring ENT for removal) 3, 1
• H91.90 - Unspecified hearing loss (requires audiologic evaluation within 4 weeks) 1, 2
• H81.90 - Unspecified disorder of vestibular function (for vertigo complaints) 2
• H93.1 - Tinnitus (specify unilateral vs. bilateral) 1, 4

Mandatory ENT Referral Indications

Refer immediately to ENT when any of these red flags are present:

High-Priority Referral Criteria

• Unilateral or asymmetric hearing loss (requires imaging to exclude vestibular schwannoma) 1, 2
• Pulsatile tinnitus (requires vascular workup) 1, 2
• Focal neurological abnormalities (cranial nerve deficits, neurological symptoms) 3
• Persistent symptoms despite appropriate initial treatment (treatment failure after 48-72 hours) 3
• Severe refractory symptoms suggesting malignant otitis externa or neoplasm 3
• Granulation tissue visible on otoscopy 3
• Suspected foreign body not easily removable 3

Moderate-Priority Referral Criteria

• Recurrent ear infections requiring specialist management 3
• Hearing loss with ear canal occlusion from cerumen or debris requiring specialized removal 3, 1
• Persistent pruritus or pain in the ear not responding to initial management 3
• Ear discharge (otorrhea) of unclear etiology 1

Audiologic Testing Requirements

Order comprehensive audiologic examination (including pure tone audiometry, speech audiometry, and acoustic reflex testing) for:

• Any unilateral ear symptoms 1, 2
• Persistent tinnitus (≥6 months) or bothersome tinnitus 1
• Any hearing difficulty reported by patient 1, 2
• Vertigo with concurrent auditory symptoms 2

The American Academy of Otolaryngology-Head and Neck Surgery emphasizes obtaining audiologic testing promptly (within 4 weeks) rather than waiting, as this helps prioritize otolaryngologic evaluation and identify unsuspected hearing loss 2.

Common Coding Pitfalls to Avoid

• Do not delay audiologic testing waiting for symptoms to persist 6 months—immediate testing is appropriate for unilateral symptoms 2
• Do not assume normal hearing based on patient report alone, as hearing loss may be unsuspected or fluctuating 2
• Do not use overly specific codes without proper diagnostic confirmation (e.g., avoid coding specific infectious etiologies without culture confirmation) 3
• Do not overlook bilateral symptoms that may still require specialist evaluation, particularly if associated with hearing loss or systemic symptoms 3

When ENT Referral May Not Be Necessary

Manage in primary care without immediate ENT referral:

• Uncomplicated acute otitis externa responding to topical antibiotics within 48-72 hours 3
• Simple cerumen impaction easily removed with irrigation or manual extraction 1
• Mild, bilateral, non-bothersome tinnitus without hearing loss or other concerning features 1

However, if symptoms persist beyond 2 weeks despite appropriate therapy, ENT referral becomes necessary 3.