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ICD-10 Guide
ICD-10 CodesH72.11

H72.11

Billable

Attic perforation of tympanic membrane, right ear

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

Code Description

ICD-10 H72.11 is a billable code used to indicate a diagnosis of attic perforation of tympanic membrane, right ear.

Key Diagnostic Point:

Attic perforation of the tympanic membrane, specifically in the right ear, refers to a defect or hole in the upper part of the eardrum, which can lead to various complications. This condition is often associated with chronic otitis media, particularly when there is a history of recurrent ear infections. Patients may present with symptoms such as hearing loss, ear discharge, and a sensation of fullness in the ear. The perforation can result from prolonged inflammation, trauma, or pressure changes. Diagnosis typically involves otoscopic examination, where the perforation is visualized, and audiometric testing to assess hearing loss. Management may include medical treatment with antibiotics for any associated infections, and in some cases, surgical intervention such as tympanoplasty may be necessary to repair the perforation and restore hearing. The presence of attic perforation can also increase the risk of cholesteatoma, a destructive skin growth in the middle ear, necessitating careful monitoring and follow-up.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Differentiating between types of tympanic membrane perforations
  • Understanding associated conditions like cholesteatoma
  • Variability in clinical presentation and severity
  • Need for precise documentation of symptoms and history

Audit Risk Factors

  • Inadequate documentation of clinical findings
  • Failure to specify the side of the perforation
  • Misclassification of the type of perforation
  • Lack of supporting audiometric data

Specialty Focus

Medical Specialties

Otolaryngology

Documentation Requirements

Detailed history of ear infections, audiometric results, and otoscopic findings.

Common Clinical Scenarios

Management of chronic otitis media with perforation, pre-operative assessments for tympanoplasty.

Billing Considerations

Ensure clear documentation of the extent of hearing loss and any surgical interventions planned.

Audiology

Documentation Requirements

Comprehensive audiometric evaluations and reports on hearing loss.

Common Clinical Scenarios

Assessment of hearing loss related to tympanic membrane perforation.

Billing Considerations

Document the impact of the perforation on hearing thresholds and speech discrimination scores.

Coding Guidelines

Inclusion Criteria

Use H72.11 When
  • Follow official ICD
  • CM guidelines for coding ear conditions, ensuring accurate documentation of the perforation's location and any associated symptoms
  • Include relevant history of ear infections or trauma

Exclusion Criteria

Do NOT use H72.11 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

69631CPT Code

Tympanoplasty, with or without mastoidectomy

Clinical Scenario

Used when surgical intervention is required for attic perforation.

Documentation Requirements

Document the indication for surgery, findings during the procedure, and post-operative care.

Specialty Considerations

Otolaryngologists must ensure that all surgical indications are well-documented to support the procedure.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of ear conditions, including attic perforation, which enhances the ability to track and manage these conditions effectively.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of ear conditions, including attic perforation, which enhances the ability to track and manage these conditions effectively.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of ear conditions, including attic perforation, which enhances the ability to track and manage these conditions effectively.

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 attic perforation?

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