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ICD-10 Guide
ICD-10 CodesH71.10

H71.10

Billable

Cholesteatoma of tympanum, unspecified ear

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

Code Description

ICD-10 H71.10 is a billable code used to indicate a diagnosis of cholesteatoma of tympanum, unspecified ear.

Key Diagnostic Point:

Cholesteatoma is an abnormal skin growth that can develop in the middle ear behind the eardrum. It often arises as a result of repeated ear infections or as a complication of chronic otitis media. The condition is characterized by the accumulation of skin cells and other debris, which can lead to the destruction of surrounding structures, including the ossicles and the mastoid process. Patients may present with symptoms such as hearing loss, ear discharge, and a feeling of fullness in the ear. In some cases, cholesteatomas can cause complications such as hearing loss, dizziness, and even intracranial infections if left untreated. Diagnosis typically involves a thorough clinical examination, audiometric testing, and imaging studies such as CT scans to assess the extent of the disease. Management often requires 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

  • Variability in clinical presentation and symptoms
  • Need for detailed documentation of surgical interventions
  • Potential for associated complications requiring additional coding
  • Differentiation from other ear conditions such as otitis media

Audit Risk Factors

  • Inadequate documentation of symptoms and clinical findings
  • Failure to document the extent of the cholesteatoma
  • Lack of clarity on the surgical procedure performed
  • Misidentification of the ear involved

Specialty Focus

Medical Specialties

Otolaryngology

Documentation Requirements

Detailed notes on patient history, physical examination findings, imaging results, and surgical details.

Common Clinical Scenarios

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

Billing Considerations

Ensure clear documentation of the surgical approach and any complications encountered during the procedure.

Audiology

Documentation Requirements

Audiometric evaluations, patient history regarding hearing loss, and any referrals for surgical intervention.

Common Clinical Scenarios

Assessment of hearing loss in patients with a known history of cholesteatoma.

Billing Considerations

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

Coding Guidelines

Inclusion Criteria

Use H71.10 When
  • Follow the official ICD
  • CM coding guidelines for coding and reporting
  • Ensure that the diagnosis is supported by clinical documentation and that the code reflects the specific condition being treated

Exclusion Criteria

Do NOT use H71.10 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

69631CPT Code

Tympanomastoid surgery

Clinical Scenario

Performed to remove cholesteatoma and reconstruct tympanic membrane.

Documentation Requirements

Operative report detailing the procedure, findings, and any complications.

Specialty Considerations

Otolaryngologists must document the extent of the cholesteatoma and any associated procedures performed.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of cholesteatoma, improving the accuracy of data collection and reimbursement processes. It has also facilitated better tracking of treatment outcomes and complications.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of cholesteatoma, improving the accuracy of data collection and reimbursement processes. It has also facilitated better tracking of treatment outcomes and complications.

Reimbursement & Billing Impact

reimbursement processes. It has also facilitated better tracking of treatment outcomes and complications.

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 are the common symptoms of cholesteatoma?

Common symptoms include hearing loss, ear discharge, a feeling of fullness in the ear, and in some cases, dizziness or balance issues.

How is cholesteatoma diagnosed?

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

What is the treatment for cholesteatoma?

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