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ICD-10 Guide
ICD-10 CodesH61.121

H61.121

Billable

Hematoma of pinna, right ear

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

Code Description

ICD-10 H61.121 is a billable code used to indicate a diagnosis of hematoma of pinna, right ear.

Key Diagnostic Point:

A hematoma of the pinna, specifically in the right ear, is a localized collection of blood outside of blood vessels, typically resulting from trauma or injury to the ear. This condition often presents as a swollen, tender area on the outer ear, which may appear discolored due to the accumulation of blood. Patients may report pain or discomfort, and in some cases, there may be associated hearing loss if the hematoma exerts pressure on surrounding structures. Diagnosis is primarily clinical, based on the history of trauma and physical examination findings. Imaging studies, such as ultrasound or CT scans, may be utilized in complicated cases to assess the extent of the hematoma and rule out other conditions. Management typically involves drainage of the hematoma to relieve pressure and prevent complications such as infection or permanent deformity of the ear. In some instances, compression dressings may be applied post-drainage to minimize the risk of re-accumulation. Follow-up care is essential to monitor for recurrence and ensure proper healing.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Requires accurate documentation of trauma history.
  • Differentiation from other ear conditions like otitis or abscess.
  • Potential for associated procedures (e.g., drainage) to be coded.
  • Need for precise anatomical localization (right ear).

Audit Risk Factors

  • Inadequate documentation of the mechanism of injury.
  • Failure to document associated symptoms like hearing loss.
  • Lack of follow-up notes post-procedure.
  • Improper coding of drainage procedures.

Specialty Focus

Medical Specialties

Otolaryngology

Documentation Requirements

Detailed notes on the mechanism of injury, physical examination findings, and treatment plan.

Common Clinical Scenarios

Trauma-related hematomas, post-surgical complications, and chronic ear conditions.

Billing Considerations

Ensure clear documentation of any surgical interventions performed.

Emergency Medicine

Documentation Requirements

Comprehensive assessment of trauma, vital signs, and immediate management steps.

Common Clinical Scenarios

Acute ear trauma, lacerations, and hematomas requiring urgent care.

Billing Considerations

Document all interventions and patient responses to treatment.

Coding Guidelines

Inclusion Criteria

Use H61.121 When
  • Follow the official ICD
  • CM coding guidelines, ensuring accurate documentation of the condition, including the specific ear affected
  • Include any relevant procedural codes if drainage or surgical intervention is performed

Exclusion Criteria

Do NOT use H61.121 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

69200CPT Code

Removal of impacted cerumen

Clinical Scenario

If cerumen impaction is present alongside the hematoma.

Documentation Requirements

Document the presence of cerumen and the procedure performed.

Specialty Considerations

Otolaryngologists may frequently encounter this scenario.

10060CPT Code

Incision and drainage of abscess

Clinical Scenario

If the hematoma becomes infected and requires drainage.

Documentation Requirements

Document the indication for drainage and any complications.

Specialty Considerations

Emergency medicine specialists often perform this procedure.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of conditions like hematomas of the pinna, improving the accuracy of medical records and billing.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of conditions like hematomas of the pinna, improving the accuracy of medical records and billing.

Reimbursement & Billing Impact

billing.

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 a hematoma of the pinna?

The primary cause is usually trauma to the ear, which can occur from sports injuries, falls, or accidents.

How is a hematoma of the pinna treated?

Treatment typically involves drainage of the hematoma to relieve pressure and prevent complications, along with monitoring for infection.

Can a hematoma of the pinna lead to hearing loss?

Yes, if the hematoma exerts pressure on the surrounding structures, it can lead to temporary hearing loss.