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ICD-10 Guide
ICD-10 CodesH71.01

H71.01

Billable

Cholesteatoma of attic, right ear

BILLABLE STATUSYes
IMPLEMENTATION DATEOctober 1, 2015
LAST UPDATED09/12/2025

Code Description

ICD-10 H71.01 is a billable code used to indicate a diagnosis of cholesteatoma of attic, right ear.

Key Diagnostic Point:

Cholesteatoma of the attic is a destructive and expanding growth of skin cells in the middle ear and/or mastoid process. It often arises from chronic otitis media, where repeated infections lead to the accumulation of skin debris and the formation of a sac-like structure. This condition can result in significant complications, including hearing loss, infection, and erosion of surrounding structures. Patients may present with symptoms such as ear discharge, hearing impairment, and sometimes pain or fullness in the ear. Diagnosis is typically made through clinical examination and imaging studies, such as CT scans, which can reveal the extent of the cholesteatoma and any associated complications. Management often involves surgical intervention to remove the cholesteatoma and reconstruct the tympanic membrane, with the goal of restoring hearing and preventing further complications.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Requires understanding of ear anatomy and pathology.
  • Differentiation from other ear conditions like otitis media.
  • Potential for associated complications that may affect coding.
  • Need for precise documentation of surgical interventions.

Audit Risk Factors

  • Inadequate documentation of clinical findings.
  • Failure to specify the affected ear.
  • Misclassification of cholesteatoma severity.
  • Lack of supporting imaging studies.

Specialty Focus

Medical Specialties

Otolaryngology

Documentation Requirements

Detailed clinical notes including history, physical examination findings, imaging results, and surgical reports.

Common Clinical Scenarios

Patients presenting with chronic ear infections, hearing loss, or post-operative follow-ups after cholesteatoma surgery.

Billing Considerations

Ensure accurate documentation of the extent of the cholesteatoma and any complications to support coding.

Audiology

Documentation Requirements

Audiometric evaluations and reports detailing the degree of hearing loss.

Common Clinical Scenarios

Assessment of hearing loss in patients with known cholesteatoma.

Billing Considerations

Document the impact of cholesteatoma on hearing and any recommendations for intervention.

Coding Guidelines

Inclusion Criteria

Use H71.01 When
  • Follow the official ICD
  • CM coding guidelines, ensuring that the diagnosis is supported by clinical documentation and that the specific ear affected is clearly indicated
  • Include any relevant complications or associated conditions in coding

Exclusion Criteria

Do NOT use H71.01 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

69631CPT Code

Tympanomastoid surgery

Clinical Scenario

Performed to remove cholesteatoma and reconstruct the tympanic membrane.

Documentation Requirements

Surgical reports detailing the procedure and findings.

Specialty Considerations

Otolaryngologists should ensure that the surgical approach and findings are well documented.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of cholesteatomas, improving the accuracy of data collection and reimbursement processes. This specificity helps in tracking outcomes and complications associated with cholesteatomas more effectively.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of cholesteatomas, improving the accuracy of data collection and reimbursement processes. This specificity helps in tracking outcomes and complications associated with cholesteatomas more effectively.

Reimbursement & Billing Impact

reimbursement processes. This specificity helps in tracking outcomes and complications associated with cholesteatomas more effectively.

Resources

Clinical References

  • •
    American Academy of Otolaryngology - Head and Neck Surgery

Coding & Billing References

  • •
    American Academy of Otolaryngology - Head and Neck Surgery

Frequently Asked Questions

What is a cholesteatoma?

A cholesteatoma is an abnormal skin growth in the middle ear that can lead to hearing loss and other complications if not treated.

How is cholesteatoma diagnosed?

Diagnosis is typically made through a combination of clinical examination, patient history, and imaging studies such as CT scans.

What are the treatment options for cholesteatoma?

Treatment usually involves surgical removal of the cholesteatoma and reconstruction of the tympanic membrane to restore hearing and prevent complications.