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ICD-10 Guide
ICD-10 CodesH71.30

H71.30

Billable

Diffuse cholesteatosis, unspecified ear

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

Code Description

ICD-10 H71.30 is a billable code used to indicate a diagnosis of diffuse cholesteatosis, unspecified ear.

Key Diagnostic Point:

Diffuse cholesteatosis is a condition characterized by the abnormal accumulation of cholesterol and other cellular debris in the middle ear and/or mastoid process. This condition can lead to chronic ear infections, hearing loss, and other complications if left untreated. Patients may present with symptoms such as ear pain, discharge, and hearing impairment. The diagnosis is typically made through a combination of clinical examination, imaging studies (such as CT scans), and audiometric testing. Management often involves surgical intervention, such as tympanomastoid surgery, to remove the cholesteatoma and restore normal ear function. The unspecified nature of this code indicates that the specific ear affected (left, right, or bilateral) is not documented, which can complicate treatment planning and coding accuracy.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Unspecified ear complicates treatment and coding.
  • Potential for co-existing conditions (e.g., otitis media).
  • Variability in clinical presentation and severity.
  • Need for surgical intervention documentation.

Audit Risk Factors

  • Lack of specificity in documentation.
  • Inadequate justification for surgical procedures.
  • Failure to document co-existing conditions.
  • Inconsistent use of codes for similar conditions.

Specialty Focus

Medical Specialties

Otolaryngology

Documentation Requirements

Detailed history of ear symptoms, audiometric results, imaging studies, and treatment plans.

Common Clinical Scenarios

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

Billing Considerations

Ensure clear documentation of the ear affected and any surgical interventions performed.

Audiology

Documentation Requirements

Comprehensive audiometric evaluations and reports on hearing loss.

Common Clinical Scenarios

Assessment of hearing loss in patients with a history of cholesteatosis.

Billing Considerations

Document the impact of cholesteatosis on hearing and any recommended interventions.

Coding Guidelines

Inclusion Criteria

Use H71.30 When
  • Follow official ICD
  • 10 coding guidelines, ensuring accurate documentation of the condition, including any associated symptoms and treatments

Exclusion Criteria

Do NOT use H71.30 When
  • Exclude conditions that are not directly related to cholesteatosis

Related ICD-10 Codes

Related CPT Codes

69631CPT Code

Tympanomastoid surgery

Clinical Scenario

Used for surgical intervention in cases of cholesteatosis.

Documentation Requirements

Document the indication for surgery and findings during the procedure.

Specialty Considerations

Otolaryngologists should ensure complete surgical notes are available.

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 plans. H71.30 reflects the need for careful documentation to avoid ambiguity in treatment.

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 plans. H71.30 reflects the need for careful documentation to avoid ambiguity in treatment.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of ear conditions, improving the accuracy of diagnoses and treatment plans. H71.30 reflects the need for careful documentation to avoid ambiguity in treatment.

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 diffuse cholesteatosis?

Diffuse cholesteatosis is a condition characterized by the accumulation of cholesterol and debris in the middle ear, which can lead to chronic infections and hearing loss.

How is diffuse cholesteatosis diagnosed?

Diagnosis is made through clinical evaluation, imaging studies, and audiometric testing to assess hearing loss.

What are the treatment options for diffuse cholesteatosis?

Treatment typically involves surgical intervention to remove the cholesteatoma and restore normal ear function.