Acute suppurative otitis media with spontaneous rupture of ear drum, bilateral
ICD-10 H66.013 is a billable code used to indicate a diagnosis of acute suppurative otitis media with spontaneous rupture of ear drum, bilateral.
Acute suppurative otitis media (ASOM) is an infection of the middle ear characterized by the presence of pus and inflammation. When this condition occurs bilaterally, it affects both ears simultaneously. The spontaneous rupture of the tympanic membrane (ear drum) is a common complication of ASOM, often resulting in the discharge of purulent material from the ear. Clinically, patients may present with ear pain, fever, irritability in children, and hearing loss. Diagnosis is typically made through clinical examination, which may reveal a bulging, red tympanic membrane, and the presence of fluid or pus in the middle ear. Management includes antibiotics to treat the infection, analgesics for pain relief, and in some cases, surgical intervention such as tympanostomy tubes may be indicated if the condition is recurrent or severe. The condition is more prevalent in children due to their anatomical differences and susceptibility to upper respiratory infections. Accurate coding is essential for proper reimbursement and tracking of healthcare outcomes.
Detailed clinical notes on examination findings, treatment plans, and follow-up care.
Management of recurrent otitis media, evaluation of hearing loss post-infection.
Ensure documentation reflects the severity of the condition and any surgical interventions performed.
Thorough history of presenting illness, including previous episodes and family history.
Acute presentations in children, management of pain and fever.
Consider age-related factors in treatment and coding, as children are more susceptible.
Performed in cases of recurrent acute otitis media with effusion.
Document indications for surgery, including frequency of infections and impact on hearing.
Otolaryngologists should ensure that all pre-operative evaluations are documented.
Accurate coding of H66.013 is crucial for proper reimbursement, tracking of healthcare outcomes, and ensuring that patients receive appropriate care based on their specific condition.
