Acute suppurative otitis media without spontaneous rupture of ear drum, unspecified ear
ICD-10 H66.009 is a billable code used to indicate a diagnosis of acute suppurative otitis media without spontaneous rupture of ear drum, unspecified ear.
Acute suppurative otitis media (ASOM) is an infection of the middle ear characterized by the presence of pus in the middle ear space. This condition typically arises from a preceding upper respiratory tract infection, leading to inflammation and blockage of the Eustachian tube. Patients often present with ear pain, fever, irritability in children, and sometimes hearing loss. In cases of ASOM without spontaneous rupture of the tympanic membrane, the ear drum remains intact, which can lead to increased pressure and pain. Diagnosis is primarily clinical, supported by otoscopic examination revealing a bulging, erythematous tympanic membrane. Management includes analgesics for pain relief and antibiotics to address the bacterial infection. In some cases, if symptoms persist or worsen, surgical intervention such as tympanostomy may be necessary to relieve pressure and drain fluid. Accurate coding is essential for appropriate treatment and reimbursement.
Detailed history of present illness, physical examination findings, and treatment plan.
Management of recurrent otitis media in pediatric patients, evaluation of hearing loss related to otitis media.
Documentation should clearly indicate the absence of tympanic membrane rupture and any prior episodes.
Complete history including vaccination status, family history of ear infections, and developmental milestones.
Assessment of acute ear pain in children, follow-up for recurrent infections.
Consideration of age-related factors in treatment decisions and documentation of parental concerns.
Often performed in conjunction with evaluation of ear pain.
Document the reason for cerumen removal and any associated symptoms.
Otolaryngologists may perform this procedure during the same visit.
Common symptoms include ear pain, fever, irritability in children, and sometimes hearing loss. Otoscopic examination typically reveals a bulging, red tympanic membrane.
Treatment usually involves pain management with analgesics and antibiotics to address the infection. In some cases, surgical intervention may be necessary.
