Otitis media, unspecified, right ear
ICD-10 H66.91 is a billable code used to indicate a diagnosis of otitis media, unspecified, right ear.
Otitis media is an inflammatory condition of the middle ear, which can be acute or chronic. The unspecified nature of this code indicates that the specific type of otitis media (e.g., serous, purulent) has not been determined. Clinically, patients may present with ear pain, fever, irritability in children, and hearing loss. The right ear designation is crucial for accurate coding, especially in cases where bilateral involvement is common. Diagnostic criteria typically include a thorough history and physical examination, often supplemented by otoscopic examination revealing fluid in the middle ear. Management may involve observation, antibiotics, or surgical interventions such as tympanostomy tube placement, particularly in recurrent cases. Accurate coding is essential for appropriate treatment reimbursement and tracking of healthcare outcomes.
Detailed history of ear symptoms, physical examination findings, and treatment plans.
Patients presenting with ear pain, drainage, or hearing loss.
Ensure clarity in documentation regarding the type and duration of otitis media.
Developmental history, vaccination status, and family history of ear infections.
Young children with recurrent ear infections requiring monitoring or intervention.
Documenting parental concerns and child’s response to treatment is crucial.
Used when recurrent otitis media necessitates tube placement.
Document indications for surgery and prior treatment attempts.
Otolaryngologists should ensure thorough pre-operative evaluations.
H66.91 is used for unspecified otitis media in the right ear, while H66.00 specifies acute serous otitis media, which is a more defined condition.
