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ICD-10 Guide
ICD-10 CodesH71.2

H71.2

Billable

Cholesteatoma of mastoid

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

Code Description

ICD-10 H71.2 is a billable code used to indicate a diagnosis of cholesteatoma of mastoid.

Key Diagnostic Point:

Cholesteatoma of the mastoid is a destructive and expanding growth of skin cells and other tissues in the middle ear and mastoid process. It often arises from chronic otitis media, where repeated infections lead to the accumulation of skin debris and other materials. The condition can result in significant complications, including hearing loss, infection, and damage to surrounding structures such as the inner ear and cranial cavity. Patients may present with symptoms such as ear discharge, hearing loss, and pain. Diagnosis typically involves otoscopic examination, imaging studies like CT scans, and audiometric testing to assess hearing function. Management often requires surgical intervention to remove the cholesteatoma and repair any associated damage, with the goal of preserving hearing and preventing further complications.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Differentiating between cholesteatoma and other ear conditions.
  • Understanding the implications of chronic otitis media.
  • Navigating surgical coding nuances related to cholesteatoma removal.
  • Documenting the extent of disease and associated complications.

Audit Risk Factors

  • Inadequate documentation of the chronic nature of the condition.
  • Failure to document associated hearing loss or complications.
  • Misclassification of cholesteatoma severity.
  • Inaccurate coding of surgical procedures performed.

Specialty Focus

Medical Specialties

Otolaryngology

Documentation Requirements

Detailed history of ear symptoms, results of physical examinations, imaging studies, and surgical notes.

Common Clinical Scenarios

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

Billing Considerations

Ensure all surgical interventions are documented, including the extent of cholesteatoma removal and any reconstruction performed.

Audiology

Documentation Requirements

Comprehensive audiometric evaluations and reports on hearing loss related to cholesteatoma.

Common Clinical Scenarios

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

Billing Considerations

Document the impact of cholesteatoma on hearing and any recommendations for hearing aids or further interventions.

Coding Guidelines

Inclusion Criteria

Use H71.2 When
  • Follow official ICD
  • 10 coding guidelines, ensuring accurate documentation of the condition's chronicity and any associated complications
  • Include relevant imaging and audiometric findings to support the diagnosis

Exclusion Criteria

Do NOT use H71.2 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

69631CPT Code

Tympanomastoid surgery

Clinical Scenario

Used for surgical intervention in cholesteatoma cases.

Documentation Requirements

Operative report detailing the procedure and findings.

Specialty Considerations

Otolaryngologists must document the extent of cholesteatoma and any reconstruction 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 diagnosis and treatment tracking. It emphasizes the need for detailed documentation of the condition's chronicity and associated complications.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of cholesteatoma, improving the accuracy of diagnosis and treatment tracking. It emphasizes the need for detailed documentation of the condition's chronicity and associated complications.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of cholesteatoma, improving the accuracy of diagnosis and treatment tracking. It emphasizes the need for detailed documentation of the condition's chronicity and associated 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 ear discharge, hearing loss, ear pain, and sometimes dizziness. Chronic otitis media is often a precursor.

How is cholesteatoma diagnosed?

Diagnosis is made through clinical examination, otoscopy, and imaging studies such as CT scans to assess the extent of the disease.

What are the treatment options for cholesteatoma?

Treatment typically involves surgical removal of the cholesteatoma and reconstruction of any damaged structures in the ear.