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ICD-10 Guide
ICD-10 CodesH71.92

H71.92

Billable

Unspecified cholesteatoma, left ear

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

Code Description

ICD-10 H71.92 is a billable code used to indicate a diagnosis of unspecified cholesteatoma, left ear.

Key Diagnostic Point:

Cholesteatoma is an abnormal skin growth that can develop in the middle ear and mastoid process, often as a result of repeated ear infections or eustachian tube dysfunction. The condition is characterized by the accumulation of skin cells and other debris, which can lead to chronic inflammation and destruction of surrounding structures. In the case of unspecified cholesteatoma of the left ear, the specific characteristics of the cholesteatoma are not detailed, making it essential for healthcare providers to document the clinical findings thoroughly. Patients may present with symptoms such as hearing loss, ear discharge, and a sensation of fullness in the ear. If left untreated, cholesteatomas can lead to serious complications, including hearing loss, infection, and damage to the surrounding structures of the ear. Diagnosis typically involves a thorough clinical examination, audiometric testing, and imaging studies such as CT scans to assess the extent of the disease. Management often requires surgical intervention to remove the cholesteatoma and repair any damage to the ear structures. Postoperative care and monitoring are crucial to prevent recurrence and manage any complications.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variability in clinical presentation and symptoms
  • Need for detailed documentation of ear examinations
  • Potential for complications requiring additional coding
  • Differentiation from other ear conditions

Audit Risk Factors

  • Inadequate documentation of clinical findings
  • Failure to specify laterality in coding
  • Lack of supporting evidence for surgical interventions
  • Misclassification of cholesteatoma severity

Specialty Focus

Medical Specialties

Otolaryngology

Documentation Requirements

Detailed descriptions of the cholesteatoma's characteristics, audiometric results, and surgical notes.

Common Clinical Scenarios

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

Billing Considerations

Ensure clear documentation of the extent of the cholesteatoma and any complications.

Audiology

Documentation Requirements

Audiometric evaluations and hearing assessments related to cholesteatoma.

Common Clinical Scenarios

Patients with hearing loss referred for audiological assessment.

Billing Considerations

Document the impact of cholesteatoma on hearing and any recommendations for intervention.

Coding Guidelines

Inclusion Criteria

Use H71.92 When
  • Follow official ICD
  • CM coding guidelines, ensuring accurate laterality and specificity
  • Include any relevant clinical findings and treatment plans in documentation to support the diagnosis

Exclusion Criteria

Do NOT use H71.92 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

69631CPT Code

Tympanomastoid surgery

Clinical Scenario

Performed to remove cholesteatoma and repair the tympanic membrane.

Documentation Requirements

Operative report detailing the procedure and findings.

Specialty Considerations

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

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for greater specificity in coding cholesteatomas, enabling better tracking of the condition and its management. H71.92 provides a clear designation for unspecified cases, which can help in understanding the prevalence and treatment outcomes.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for greater specificity in coding cholesteatomas, enabling better tracking of the condition and its management. H71.92 provides a clear designation for unspecified cases, which can help in understanding the prevalence and treatment outcomes.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for greater specificity in coding cholesteatomas, enabling better tracking of the condition and its management. H71.92 provides a clear designation for unspecified cases, which can help in understanding the prevalence and treatment outcomes.

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 chronic infection and damage to surrounding structures.

How is cholesteatoma diagnosed?

Diagnosis typically involves a clinical examination, audiometric testing, and imaging studies such as CT scans.

What are the treatment options for cholesteatoma?

Treatment often involves surgical removal of the cholesteatoma and repair of any damage to the ear structures.