Disorder of right external ear, unspecified
ICD-10 H61.91 is a billable code used to indicate a diagnosis of disorder of right external ear, unspecified.
The code H61.91 refers to unspecified disorders of the right external ear, which can encompass a variety of conditions affecting the outer ear structure, including the auricle and external auditory canal. Common presentations may include ear pain, itching, discharge, or swelling. Conditions such as otitis externa (inflammation of the outer ear), cerumen impaction, and trauma can lead to this diagnosis. Patients may present with symptoms like hearing loss, discomfort, or visible abnormalities in the ear. Diagnosis typically involves a thorough clinical examination, including otoscopic evaluation, and may require imaging studies in complex cases. Management strategies vary based on the underlying cause and may include topical medications, ear cleaning, or surgical interventions in cases of severe infection or structural abnormalities. Accurate coding is essential for appropriate treatment and reimbursement, necessitating detailed documentation of clinical findings and treatment plans.
Detailed examination findings, treatment plans, and follow-up notes.
Management of otitis externa, cerumen impaction, and trauma to the ear.
Ensure clarity in documentation to support the diagnosis and treatment provided.
Comprehensive patient history, symptom description, and initial treatment plans.
Initial evaluation of ear pain or discomfort, referral to specialists.
Documenting the rationale for referrals and any preliminary treatments administered.
Used when cerumen impaction is treated in conjunction with H61.91.
Document the procedure performed and the reason for cerumen removal.
Otolaryngologists may perform this procedure more frequently than primary care providers.
Use H61.91 when a patient presents with symptoms related to the right external ear, but no specific diagnosis can be made. Ensure that documentation supports the use of this unspecified code.
