Acute suppurative otitis media with spontaneous rupture of ear drum, left ear
ICD-10 H66.012 is a billable code used to indicate a diagnosis of acute suppurative otitis media with spontaneous rupture of ear drum, left ear.
Acute suppurative otitis media (ASOM) is an infection of the middle ear characterized by the presence of pus and inflammation. This condition often arises from upper respiratory infections, leading to fluid accumulation and pressure build-up in the middle ear. In cases where the pressure becomes too great, the tympanic membrane (ear drum) may spontaneously rupture, resulting in the discharge of pus and relief of pressure. Clinically, patients may present with ear pain, fever, irritability in children, and hearing loss. The left ear designation indicates the affected side, which is crucial for accurate diagnosis and treatment. Diagnosis is typically confirmed through otoscopic examination, revealing a bulging, red tympanic membrane with possible perforation. Management includes antibiotics to address the infection, analgesics for pain relief, and in some cases, surgical intervention such as tympanostomy may be necessary if the condition is recurrent or complications arise. Proper coding is essential for reimbursement and tracking of healthcare outcomes.
Detailed clinical notes on symptoms, examination findings, and treatment plans.
Management of acute otitis media, tympanostomy tube placement, and treatment of complications.
Ensure clear documentation of the ear affected and any surgical interventions performed.
Thorough history of presenting illness, including fever, irritability, and feeding difficulties.
Diagnosis and management of ear infections in children, including follow-up care.
Document developmental milestones and any recurrent infections for accurate coding.
Used when a patient with recurrent acute otitis media requires drainage.
Surgical notes detailing the procedure and indication for tympanostomy.
Otolaryngologists must document the frequency of infections and previous treatments.
Common symptoms include ear pain, fever, irritability in children, and hearing loss. Patients may also experience drainage from the ear if the tympanic membrane has ruptured.
