Central perforation of tympanic membrane
ICD-10 H72.0 is a billable code used to indicate a diagnosis of central perforation of tympanic membrane.
Central perforation of the tympanic membrane, commonly referred to as a ruptured eardrum, occurs when there is a hole or tear in the membrane that separates the outer ear from the middle ear. This condition can arise from various causes, including acute otitis media, chronic ear infections, trauma, or sudden pressure changes. Clinically, patients may present with symptoms such as ear pain, hearing loss, tinnitus, and discharge from the ear. The perforation can be diagnosed through otoscopic examination, where the physician can visualize the tympanic membrane and assess the size and location of the perforation. Management typically involves addressing the underlying cause, such as treating infections with antibiotics, and in some cases, surgical intervention may be necessary to repair the membrane. The prognosis is generally favorable, with many perforations healing spontaneously, although some may require tympanoplasty for complete closure. Accurate coding is essential for proper reimbursement and to reflect the complexity of the patient's condition.
Detailed notes on the patient's history, physical examination findings, and treatment plan, including any imaging studies.
Patients presenting with ear pain, hearing loss, or discharge, often following a respiratory infection.
Ensure clear documentation of the size and location of the perforation, as well as any surgical interventions performed.
Comprehensive history and physical examination, including symptom duration and any prior treatments.
Initial evaluation of ear pain or suspected ear infections in children and adults.
Document any referrals to specialists and the rationale for further evaluation or treatment.
Used when surgical repair of the tympanic membrane is necessary.
Operative report detailing the procedure and indication for surgery.
Otolaryngologists must document the extent of the perforation and any associated middle ear pathology.
Common causes include acute otitis media, chronic ear infections, trauma, and barotrauma. Each cause may require different management strategies.
