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ICD-10 Guide
ICD-10 CodesH71.22

H71.22

Billable

Cholesteatoma of mastoid, left ear

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

Code Description

ICD-10 H71.22 is a billable code used to indicate a diagnosis of cholesteatoma of mastoid, left ear.

Key Diagnostic Point:

Cholesteatoma of the mastoid process is a destructive and expanding growth of skin cells and other debris that occurs in the middle ear and/or mastoid process. This condition often arises as a complication of chronic otitis media, where repeated infections lead to the formation of a sac-like structure filled with keratin and other cellular debris. Patients may present with symptoms such as ear discharge, hearing loss, and sometimes pain or discomfort in the affected ear. The left ear designation indicates that the condition is localized to the left mastoid process. Diagnosis typically involves a thorough clinical examination, audiometric testing, and imaging studies such as CT scans to assess the extent of the cholesteatoma and its impact on surrounding structures. Management often requires surgical intervention, including tympanomastoid surgery, to remove the cholesteatoma and restore hearing. Postoperative care is crucial to monitor for recurrence and manage any complications.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Differentiation from other ear conditions such as otitis media and other types of cholesteatomas.
  • Need for precise documentation of the location and extent of the cholesteatoma.
  • Potential for associated complications that may require additional coding.
  • Variability in surgical procedures and their coding based on the extent of the disease.

Audit Risk Factors

  • Inadequate documentation of the clinical findings leading to the diagnosis.
  • Failure to document the surgical procedure performed.
  • Misclassification of the cholesteatoma type or location.
  • Lack of follow-up documentation post-surgery.

Specialty Focus

Medical Specialties

Otolaryngology

Documentation Requirements

Detailed clinical notes on the patient's 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 clear documentation of the extent of the cholesteatoma and any associated complications.

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 the cholesteatoma on hearing and any recommendations for rehabilitation.

Coding Guidelines

Inclusion Criteria

Use H71.22 When
  • Follow the official ICD
  • CM coding guidelines, ensuring accurate documentation of the diagnosis, including the specific location and any associated conditions
  • existing

Exclusion Criteria

Do NOT use H71.22 When
  • Exclude codes for other types of ear diseases unless they are co

Related ICD-10 Codes

Related CPT Codes

69631CPT Code

Tympanomastoid surgery

Clinical Scenario

Used for surgical intervention in patients diagnosed with cholesteatoma.

Documentation Requirements

Surgical reports detailing the procedure performed and findings.

Specialty Considerations

Otolaryngologists must document the extent of the cholesteatoma and any complications encountered.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of ear conditions, improving the accuracy of diagnoses and treatment tracking. H71.22 provides a clear distinction for cholesteatoma of the left mastoid, enhancing clinical data collection and reimbursement processes.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of ear conditions, improving the accuracy of diagnoses and treatment tracking. H71.22 provides a clear distinction for cholesteatoma of the left mastoid, enhancing clinical data collection and reimbursement processes.

Reimbursement & Billing Impact

reimbursement processes.

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, and sometimes pain or discomfort in the affected ear. Patients may also experience dizziness or balance issues if the condition affects the inner ear.

How is cholesteatoma diagnosed?

Diagnosis typically involves a clinical examination, audiometric testing, and imaging studies such as CT scans to assess the extent of the cholesteatoma.

What is the treatment for cholesteatoma?

Treatment usually involves surgical intervention to remove the cholesteatoma and restore hearing, along with follow-up care to monitor for recurrence.