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ICD-10 Guide
ICD-10 CodesH71.00

H71.00

Billable

Cholesteatoma of attic, unspecified ear

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

Code Description

ICD-10 H71.00 is a billable code used to indicate a diagnosis of cholesteatoma of attic, unspecified ear.

Key Diagnostic Point:

Cholesteatoma of the attic is a destructive and expanding growth of skin cells in the middle ear and/or mastoid process. This condition often arises from chronic otitis media, where repeated infections lead to the accumulation of skin cells and debris in the attic (the upper part of the middle ear). Patients may present with symptoms such as hearing loss, ear fullness, and sometimes discharge from the ear. The cholesteatoma can erode surrounding structures, leading to complications such as hearing loss, dizziness, and even facial nerve paralysis if left untreated. Diagnosis typically involves otoscopic examination, audiometric testing, and imaging studies like CT scans to assess the extent of the disease. Management often requires surgical intervention to remove the cholesteatoma and reconstruct the tympanic membrane to restore hearing and prevent recurrence. Regular follow-up is essential to monitor for potential complications or recurrence of the cholesteatoma.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Differentiating between cholesteatoma types (e.g., acquired vs. congenital)
  • Need for detailed documentation of clinical findings and imaging results
  • Potential for complications requiring additional coding
  • Variability in surgical procedures and their coding

Audit Risk Factors

  • Inadequate documentation of the extent of the cholesteatoma
  • Failure to document associated symptoms or complications
  • Incorrect coding of surgical procedures related to cholesteatoma
  • Lack of follow-up documentation post-surgery

Specialty Focus

Medical Specialties

Otolaryngology

Documentation Requirements

Detailed clinical notes including history, physical examination findings, imaging results, and surgical reports.

Common Clinical Scenarios

Patients presenting with chronic ear infections, hearing loss, or post-surgical follow-ups.

Billing Considerations

Ensure clear documentation of the cholesteatoma's location and any complications to support coding.

Audiology

Documentation Requirements

Audiometric evaluations and reports detailing the degree of hearing loss.

Common Clinical Scenarios

Patients undergoing hearing assessments pre- and post-surgery for cholesteatoma.

Billing Considerations

Document the impact of cholesteatoma on hearing and any rehabilitative measures taken.

Coding Guidelines

Inclusion Criteria

Use H71.00 When
  • Follow the official ICD
  • CM coding guidelines for coding and reporting
  • Ensure that the diagnosis is supported by clinical documentation and that any associated conditions are also coded appropriately

Exclusion Criteria

Do NOT use H71.00 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

69631CPT Code

Tympanomastoid surgery

Clinical Scenario

Used for surgical removal of cholesteatoma and reconstruction of the tympanic membrane.

Documentation Requirements

Surgical reports detailing the procedure and findings.

Specialty Considerations

Otolaryngologists must document the extent of the cholesteatoma and any complications encountered during surgery.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of cholesteatomas, improving the accuracy of data collection and reimbursement processes. The granularity of ICD-10 codes helps in better tracking of treatment outcomes and complications.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of cholesteatomas, improving the accuracy of data collection and reimbursement processes. The granularity of ICD-10 codes helps in better tracking of treatment outcomes and complications.

Reimbursement & Billing Impact

reimbursement processes. The granularity of ICD-10 codes helps in better tracking of treatment outcomes and complications.

Resources

Clinical References

  • •
    American Academy of Otolaryngology - Head and Neck Surgery

Coding & Billing References

  • •
    American Academy of Otolaryngology - Head and Neck Surgery

Frequently Asked Questions

What is a cholesteatoma?

A cholesteatoma is an abnormal skin growth in the middle ear that can lead to serious complications if not treated. It often results from chronic ear infections.

How is cholesteatoma diagnosed?

Diagnosis is made through clinical examination, audiometric testing, and imaging studies such as CT scans to assess the extent of the disease.

What are the treatment options for cholesteatoma?

Treatment typically involves surgical removal of the cholesteatoma and reconstruction of the tympanic membrane to restore hearing and prevent recurrence.