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ICD-10 Guide
ICD-10 CodesH91.91

H91.91

Billable

Unspecified hearing loss, right ear

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

Code Description

ICD-10 H91.91 is a billable code used to indicate a diagnosis of unspecified hearing loss, right ear.

Key Diagnostic Point:

Unspecified hearing loss in the right ear refers to a reduction in the ability to hear sounds in the right ear without a specific diagnosis indicating the cause or type of hearing loss. This condition can arise from various etiologies, including age-related changes, noise exposure, ototoxic medications, infections, or trauma. Patients may present with symptoms such as difficulty understanding speech, asking for repetition, or an overall sensation of muffled hearing. Diagnostic evaluation typically includes audiometric testing to assess the degree and type of hearing loss, along with a thorough history and physical examination to rule out underlying conditions such as otitis media, cerumen impaction, or vestibular disorders. Management may involve hearing aids, assistive listening devices, or referral for further evaluation if a specific cause is identified. The unspecified nature of this code indicates that further investigation may be necessary to determine the underlying cause of the hearing loss.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variability in clinical presentation and underlying causes
  • Need for comprehensive audiometric testing
  • Potential for co-existing conditions affecting hearing
  • Documentation requirements for unspecified conditions

Audit Risk Factors

  • Lack of detailed documentation supporting the unspecified nature
  • Inadequate audiometric testing records
  • Failure to rule out other specific hearing loss codes
  • Inconsistent clinical notes regarding patient symptoms

Specialty Focus

Medical Specialties

Otolaryngology

Documentation Requirements

Detailed history of hearing loss, audiometric test results, and any relevant imaging studies.

Common Clinical Scenarios

Patients presenting with gradual hearing loss, sudden hearing loss, or complaints of tinnitus.

Billing Considerations

Ensure that all potential causes of hearing loss are explored and documented to avoid unspecified coding.

Audiology

Documentation Requirements

Comprehensive audiological evaluations, including pure-tone audiometry and speech recognition tests.

Common Clinical Scenarios

Routine hearing assessments for patients with risk factors for hearing loss.

Billing Considerations

Documentation must clearly indicate the need for further evaluation or management recommendations.

Coding Guidelines

Inclusion Criteria

Use H91.91 When
  • According to ICD
  • 10 guidelines, H91
  • 91 should be used when the specific cause of hearing loss is not documented
  • Coders should ensure that the medical record supports the use of this code and that all other potential codes have been considered

Exclusion Criteria

Do NOT use H91.91 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

92557CPT Code

Comprehensive audiometry threshold evaluation and speech recognition

Clinical Scenario

Used when a patient presents with hearing loss for evaluation.

Documentation Requirements

Audiometric test results must be documented in the medical record.

Specialty Considerations

Otolaryngologists and audiologists should ensure that the evaluation aligns with the diagnosis.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of hearing loss, but the use of unspecified codes like H91.91 remains common. Coders must ensure that they are using the most accurate codes available to reflect the patient's condition.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of hearing loss, but the use of unspecified codes like H91.91 remains common. Coders must ensure that they are using the most accurate codes available to reflect the patient's condition.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of hearing loss, but the use of unspecified codes like H91.91 remains common. Coders must ensure that they are using the most accurate codes available to reflect the patient's condition.

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

When should I use H91.91?

Use H91.91 when a patient presents with hearing loss in the right ear, and the specific cause or type of hearing loss has not been determined or documented.