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ICD-10 Guide
ICD-10 CodesH71.31

H71.31

Billable

Diffuse cholesteatosis, right ear

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

Code Description

ICD-10 H71.31 is a billable code used to indicate a diagnosis of diffuse cholesteatosis, right ear.

Key Diagnostic Point:

Diffuse cholesteatosis of the right ear is a condition characterized by the abnormal accumulation of skin cells and other debris in the middle ear and/or mastoid process. This condition often arises from chronic otitis media, where repeated infections lead to the formation of a cyst-like structure filled with keratin and other materials. Patients may present with symptoms such as hearing loss, ear fullness, and recurrent ear infections. The presence of cholesteatoma can lead to further complications, including erosion of surrounding structures, facial nerve paralysis, and 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 repair any associated damage to the ear structures. Post-operative care and regular follow-up are essential to monitor for recurrence and manage any residual hearing loss.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Requires understanding of ear anatomy and pathology
  • Differentiation from other ear conditions like otitis media
  • Need for precise documentation of surgical interventions
  • Potential for complications that may alter coding

Audit Risk Factors

  • Inadequate documentation of clinical findings
  • Failure to specify laterality (right ear)
  • Lack of supporting imaging studies
  • Inconsistent coding of associated conditions

Specialty Focus

Medical Specialties

Otolaryngology

Documentation Requirements

Detailed clinical notes, imaging results, and surgical reports are essential.

Common Clinical Scenarios

Management of chronic ear infections, cholesteatoma surgeries, and hearing loss evaluations.

Billing Considerations

Ensure clear documentation of the extent of cholesteatosis and any complications.

Audiology

Documentation Requirements

Audiometric evaluations and hearing loss assessments must be documented.

Common Clinical Scenarios

Assessment of hearing loss related to cholesteatosis and post-operative hearing evaluations.

Billing Considerations

Link audiological findings to the diagnosis of cholesteatosis for accurate coding.

Coding Guidelines

Inclusion Criteria

Use H71.31 When
  • Follow official ICD
  • CM guidelines for coding ear conditions, ensuring accurate documentation of laterality and any associated procedures
  • Include relevant clinical findings and imaging results

Exclusion Criteria

Do NOT use H71.31 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 cholesteatosis.

Documentation Requirements

Surgical reports must detail the procedure and findings.

Specialty Considerations

Otolaryngologists must document the extent of disease and any complications.

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. H71.31 provides a clear distinction for diffuse cholesteatosis in the right ear, enhancing clinical data quality.

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. H71.31 provides a clear distinction for diffuse cholesteatosis in the right ear, enhancing clinical data quality.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of ear conditions, improving the accuracy of diagnoses and treatment tracking. H71.31 provides a clear distinction for diffuse cholesteatosis in the right ear, enhancing clinical data quality.

Resources

Clinical References

  • •
    ICD-10-CM Official Guidelines for Coding and Reporting

Coding & Billing References

  • •
    ICD-10-CM Official Guidelines for Coding and Reporting

Frequently Asked Questions

What is the primary cause of diffuse cholesteatosis?

Diffuse cholesteatosis is primarily caused by chronic otitis media, leading to the accumulation of skin cells and debris in the middle ear.

How is diffuse cholesteatosis diagnosed?

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

What are the treatment options for diffuse cholesteatosis?

Treatment typically involves surgical intervention to remove the cholesteatoma and repair any damage to the ear structures.