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v1.0.0
ICD-10 Guide
ICD-10 CodesH71.1

H71.1

Billable

Cholesteatoma of tympanum

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

Code Description

ICD-10 H71.1 is a billable code used to indicate a diagnosis of cholesteatoma of tympanum.

Key Diagnostic Point:

Cholesteatoma of the tympanum is an abnormal skin growth that occurs in the middle ear behind the eardrum. It often results from repeated ear infections or a malfunctioning Eustachian tube, leading to the accumulation of skin cells and other debris. This condition can cause chronic ear infections, hearing loss, and, if left untreated, can lead to more severe complications such as the erosion of surrounding structures, including the mastoid bone. Patients may present with symptoms such as ear discharge, hearing impairment, and a sensation of fullness in the ear. Diagnosis is typically confirmed through otoscopic examination, imaging studies like CT scans, and audiometric testing. Management often involves surgical intervention to remove the cholesteatoma and repair any damage to the ear structures, with the goal of restoring hearing and preventing 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 and other ear conditions
  • Need for detailed documentation of surgical interventions
  • Potential for complications requiring additional coding
  • Variability in clinical presentation among patients

Audit Risk Factors

  • Inadequate documentation of symptoms and clinical findings
  • Failure to document the surgical procedure performed
  • Misclassification of cholesteatoma type
  • Lack of follow-up documentation post-surgery

Specialty Focus

Medical Specialties

Otolaryngology

Documentation Requirements

Detailed surgical notes, pre-operative and post-operative assessments, and audiometric evaluations.

Common Clinical Scenarios

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

Billing Considerations

Ensure all relevant findings from imaging studies are documented to support the diagnosis.

Audiology

Documentation Requirements

Comprehensive audiometric testing results and patient history related to hearing loss.

Common Clinical Scenarios

Assessment of hearing loss in patients with known cholesteatoma.

Billing Considerations

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

Coding Guidelines

Inclusion Criteria

Use H71.1 When
  • Follow the official ICD
  • CM guidelines for coding and reporting, ensuring accurate documentation of the condition and any associated procedures
  • Include details of the surgical approach and any complications encountered

Exclusion Criteria

Do NOT use H71.1 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

69631CPT Code

Tympanomastoid surgery

Clinical Scenario

Used for surgical removal of cholesteatoma.

Documentation Requirements

Detailed operative report and post-operative care notes.

Specialty Considerations

Otolaryngologists must document the extent of the cholesteatoma and any complications.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of cholesteatoma, improving the accuracy of data collection and reimbursement processes. It has also enhanced the ability to track outcomes and complications associated with this condition.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of cholesteatoma, improving the accuracy of data collection and reimbursement processes. It has also enhanced the ability to track outcomes and complications associated with this condition.

Reimbursement & Billing Impact

reimbursement processes. It has also enhanced the ability to track outcomes and complications associated with this condition.

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 are the common symptoms of cholesteatoma?

Common symptoms include ear discharge, hearing loss, and a feeling of fullness in the ear. Patients may also experience pain or discomfort.

How is cholesteatoma diagnosed?

Diagnosis is typically made through otoscopic examination, imaging studies such as CT scans, and audiometric testing to assess hearing loss.

What is the treatment for cholesteatoma?

The primary treatment for cholesteatoma is surgical removal. In some cases, additional procedures may be necessary to repair any damage caused by the cholesteatoma.