Attic perforation of tympanic membrane, unspecified ear
ICD-10 H72.10 is a billable code used to indicate a diagnosis of attic perforation of tympanic membrane, unspecified ear.
Attic perforation of the tympanic membrane refers to a specific type of eardrum perforation that occurs in the attic region of the tympanic membrane, which is the upper part of the eardrum. This condition is often associated with chronic otitis media, particularly when there is a cholesteatoma present. Patients may present with symptoms such as hearing loss, ear discharge, and sometimes pain or discomfort in the ear. The perforation can lead to complications such as further hearing loss, infection, or the spread of infection to surrounding structures. Diagnosis typically involves otoscopic examination, where the physician can visualize the perforation and assess its size and location. Imaging studies, such as CT scans, may be utilized to evaluate the extent of any associated conditions, particularly if a cholesteatoma is suspected. Management may include medical treatment with antibiotics for any infection, and surgical intervention may be necessary to repair the perforation and address any underlying issues. Surgical options include tympanoplasty or mastoidectomy, depending on the severity and nature of the condition. Accurate coding is essential for proper reimbursement and tracking of healthcare outcomes.
Detailed otoscopic findings, size and location of the perforation, and any associated conditions.
Patients presenting with chronic ear infections, hearing loss, or recurrent ear discharge.
Ensure documentation reflects the clinical rationale for surgical intervention if performed.
Audiometric evaluations and assessments of hearing loss related to the perforation.
Patients undergoing hearing assessments post-perforation or post-surgery.
Document the impact of the perforation on hearing thresholds and any rehabilitative measures taken.
Used when surgical repair of the tympanic membrane is performed due to attic perforation.
Document the indication for surgery, findings during the procedure, and postoperative care.
Otolaryngologists should ensure that the surgical approach is clearly documented.
Specifying the ear is crucial for accurate diagnosis and treatment planning, as management may differ based on whether the right or left ear is affected.
