Unspecified cholesteatoma, unspecified ear
ICD-10 H71.90 is a billable code used to indicate a diagnosis of unspecified cholesteatoma, unspecified ear.
Cholesteatoma is an abnormal skin growth that can develop in the middle ear and/or mastoid process, often as a result of chronic ear infections. It can lead to the destruction of surrounding structures and may cause hearing loss, pain, and other complications. The unspecified nature of this code indicates that the specific location of the cholesteatoma within the ear is not documented. Clinical presentation may include symptoms such as ear discharge, hearing loss, and a feeling of fullness in the ear. Diagnosis typically involves a thorough history, physical examination, and imaging studies such as CT scans to assess the extent of the cholesteatoma and any associated complications. Management often requires surgical intervention to remove the cholesteatoma and repair any damage to the ear structures. Postoperative care and monitoring for recurrence are essential components of management. Accurate coding is crucial for proper reimbursement and tracking of healthcare outcomes.
Detailed clinical notes including history, physical examination findings, imaging results, and treatment plans.
Patients presenting with chronic ear infections, hearing loss, or post-surgical follow-ups.
Ensure clear documentation of the cholesteatoma's location and any complications to support coding.
Audiometric evaluations and reports detailing hearing loss and its impact on daily living.
Assessment of hearing loss in patients with a history of cholesteatoma.
Document the relationship between cholesteatoma and hearing impairment for accurate coding.
Used for surgical intervention in patients diagnosed with cholesteatoma.
Operative reports detailing the procedure and findings.
Otolaryngologists must document the extent of the cholesteatoma and any complications encountered.
A cholesteatoma is an abnormal skin growth in the middle ear that can lead to hearing loss and other complications. It often results from chronic ear infections.
Diagnosis is typically made through a combination of patient history, physical examination, and imaging studies such as CT scans.
Treatment usually involves surgical removal of the cholesteatoma and reconstruction of the tympanic membrane to prevent recurrence.
