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ICD-10 Guide
ICD-10 CodesH71.13

H71.13

Billable

Cholesteatoma of tympanum, bilateral

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

Code Description

ICD-10 H71.13 is a billable code used to indicate a diagnosis of cholesteatoma of tympanum, bilateral.

Key Diagnostic Point:

Cholesteatoma is an abnormal skin growth in the middle ear behind the eardrum, often resulting from repeated ear infections or Eustachian tube dysfunction. In bilateral cases, both ears are affected, leading to a range of complications including hearing loss, chronic ear infections, and potential damage to surrounding structures such as the mastoid process. Patients may present with symptoms such as ear discharge, hearing impairment, and a sensation of fullness in the ear. Diagnosis typically involves otoscopic examination, audiometric testing, and imaging studies like CT scans to assess the extent of the cholesteatoma and any associated complications. Management often requires surgical intervention, such as tympanomastoid surgery, to remove the cholesteatoma and reconstruct the tympanic membrane. Postoperative care is crucial to monitor for recurrence and manage any complications.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Bilateral nature complicates documentation and coding.
  • Requires detailed clinical history and examination findings.
  • Potential for associated conditions (e.g., hearing loss) that must be coded appropriately.
  • Surgical interventions may vary, affecting coding specificity.

Audit Risk Factors

  • Inadequate documentation of bilateral involvement.
  • Failure to document associated conditions like hearing loss.
  • Lack of clarity in surgical procedure documentation.
  • Inconsistent coding of follow-up visits and complications.

Specialty Focus

Medical Specialties

Otolaryngology

Documentation Requirements

Detailed clinical notes on symptoms, examination findings, and imaging results.

Common Clinical Scenarios

Patients presenting with chronic ear infections, hearing loss, or post-surgical follow-ups.

Billing Considerations

Ensure clear documentation of the extent of cholesteatoma and any surgical interventions performed.

Audiology

Documentation Requirements

Audiometric evaluations and reports on hearing loss severity.

Common Clinical Scenarios

Patients undergoing hearing assessments post-cholesteatoma surgery.

Billing Considerations

Document the relationship between cholesteatoma and hearing loss for accurate coding.

Coding Guidelines

Inclusion Criteria

Use H71.13 When
  • Follow official ICD
  • 10 coding guidelines, ensuring accurate documentation of bilateral involvement
  • Include any associated conditions such as hearing loss or chronic otitis media
  • Ensure compliance with payer
  • specific guidelines

Exclusion Criteria

Do NOT use H71.13 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

69631CPT Code

Tympanomastoid surgery

Clinical Scenario

Used for surgical intervention in cases of cholesteatoma.

Documentation Requirements

Document the extent of the cholesteatoma and surgical findings.

Specialty Considerations

Otolaryngologists should ensure detailed operative notes.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of conditions like cholesteatoma, improving the accuracy of patient records and facilitating better management of ear diseases.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of conditions like cholesteatoma, improving the accuracy of patient records and facilitating better management of ear diseases.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of conditions like cholesteatoma, improving the accuracy of patient records and facilitating better management of ear diseases.

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 bilateral cholesteatoma?

Common symptoms include ear discharge, hearing loss, and a feeling of fullness in the ears. Patients may also experience balance issues if the vestibular system is affected.