What is the appropriate ICD (International Classification of Diseases) code for a 9-month-old infant presenting with ear pulling and teething symptoms, but no evidence of an ear infection?

ICD-10 Coding for Ear Pulling and Teething Without Ear Infection

For a 9-month-old infant with ear pulling and teething but no evidence of ear infection, the appropriate ICD-10 code is R63.2 (Excessive crying of infant/child) or R68.13 (Apparent life threatening event in infant) if the behavior is concerning, but most accurately R52 (Pain, unspecified) or more specifically H92.09 (Otalgia, unspecified ear) for the ear-related symptom, combined with K00.7 (Teething syndrome).

Primary Coding Approach

Teething as the Principal Diagnosis

• K00.7 (Teething syndrome) is the most appropriate primary code when teething is the documented cause of symptoms 1, 2
• This code captures the developmental process causing discomfort without implying pathology 1

Ear Pulling Without Infection

• H92.09 (Otalgia, unspecified ear) can be used as a secondary code if ear pain/pulling is a prominent presenting symptom 3
• This code is appropriate when the symptom is documented but no otitis media is diagnosed on examination 4, 5

Critical Diagnostic Exclusions

Ruling Out Acute Otitis Media

Before coding as teething alone, you must document that the infant does not meet diagnostic criteria for AOM, which requires all three elements 4, 5:

• Acute onset of symptoms (ear pain, irritability, fever)
• Middle ear effusion confirmed by pneumatic otoscopy or tympanometry
• Signs of middle ear inflammation (tympanic membrane bulging or distinct erythema)

Documentation Requirements

• Document normal otoscopic examination findings explicitly 3, 4
• Note that tympanic membrane is not bulging, erythematous, or showing effusion 5
• Record that pneumatic otoscopy (if performed) shows normal tympanic membrane mobility 4

Common Clinical Pitfalls

Avoiding Misdiagnosis

• Do not assume ear pulling equals ear infection - studies show weak associations between teething symptoms and actual pathology 2
• Parental beliefs about teething causing various symptoms often exceed evidence-based associations 1, 2
• A cohort study of 90 tooth eruptions found no significant association between tooth eruption and most reported symptoms, including fever 2

Age-Appropriate Context

• At 9 months, this infant is at peak age for both teething and otitis media (6-24 months) 3
• Maternal antibodies are waning at this age, increasing susceptibility to actual infections 1
• Critical: Do not let teething diagnosis delay recognition of true ear infection if symptoms worsen 1

Alternative Coding Considerations

If Behavioral Symptoms Predominate

• R68.12 (Fussy infant/baby) may be appropriate if irritability is the chief complaint 1
• R63.3 (Feeding difficulties) if teething affects feeding behavior 1

If Examination Shows Effusion Without Inflammation

• If middle ear effusion is present without signs of acute inflammation, code as H65.90 (Otitis media with effusion, unspecified) instead 3
• This requires tympanometry or pneumatic otoscopy showing reduced mobility 3, 4

Documentation Best Practices

Support Your Coding

Document the following to justify non-infection coding 4, 5:

• Normal tympanic membrane appearance (color, position, translucency)
• Absence of bulging or air-fluid levels
• Normal or mildly decreased mobility on pneumatic otoscopy
• Presence of erupting teeth or swollen gums
• Behavioral symptoms consistent with teething discomfort

Follow-Up Instructions

• Educate parents that ear pulling alone does not indicate infection 1, 2
• Provide return precautions if fever >39°C, persistent crying, or purulent ear discharge develops 4, 5
• These would necessitate re-evaluation and potential recoding if AOM develops 4