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v1.0.0
ICD-10 Guide
ICD-10 CodesH92.21

H92.21

Billable

Otorrhagia, right ear

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

Code Description

ICD-10 H92.21 is a billable code used to indicate a diagnosis of otorrhagia, right ear.

Key Diagnostic Point:

Otorrhagia, or ear bleeding, specifically from the right ear, can be indicative of various underlying conditions affecting the ear and mastoid process. This condition may arise from trauma, infections such as otitis media or externa, or neoplastic processes. Clinical presentation often includes visible blood in the ear canal, which may be accompanied by pain, hearing loss, or discharge. Diagnostic criteria typically involve a thorough history and physical examination, including otoscopic evaluation to identify the source of bleeding. Management may include addressing the underlying cause, such as treating infections with antibiotics, managing trauma with appropriate wound care, or surgical interventions if necessary. It is crucial for healthcare providers to document the clinical findings and any associated symptoms to ensure accurate coding and reimbursement.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Differentiating between various types of ear bleeding (e.g., traumatic vs. non-traumatic)
  • Identifying associated conditions such as otitis media or external ear infections
  • Documenting the severity and duration of symptoms
  • Understanding the need for potential surgical interventions

Audit Risk Factors

  • Inadequate documentation of the cause of bleeding
  • Failure to document associated symptoms or conditions
  • Misuse of unspecified codes when more specific codes are available
  • Inconsistent coding of related procedures or treatments

Specialty Focus

Medical Specialties

Otolaryngology

Documentation Requirements

Detailed history of present illness, physical examination findings, and any imaging studies performed.

Common Clinical Scenarios

Patients presenting with ear pain, bleeding, or discharge, often following trauma or infection.

Billing Considerations

Ensure that all findings are documented clearly to support the diagnosis and any surgical interventions.

Primary Care

Documentation Requirements

Comprehensive patient history, including any recent illnesses or injuries, and a thorough examination of the ear.

Common Clinical Scenarios

Patients with acute ear pain and bleeding, often referred to specialists for further evaluation.

Billing Considerations

Documenting the rationale for referral to specialists can aid in coding and billing.

Coding Guidelines

Inclusion Criteria

Use H92.21 When
  • According to ICD
  • 10 guidelines, H92
  • 21 should be used when the bleeding is specifically from the right ear
  • Coders must ensure that the documentation supports the diagnosis and that any related conditions are also coded appropriately

Exclusion Criteria

Do NOT use H92.21 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

69210CPT Code

Removal of impacted cerumen

Clinical Scenario

Often performed when bleeding is associated with cerumen impaction.

Documentation Requirements

Document the reason for cerumen removal and any findings during the procedure.

Specialty Considerations

Otolaryngologists may perform this procedure in conjunction with other evaluations.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of conditions like otorrhagia, improving the accuracy of data collection and reimbursement processes.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of conditions like otorrhagia, improving the accuracy of data collection and reimbursement processes.

Reimbursement & Billing Impact

reimbursement processes.

Resources

Clinical References

  • •
    ICD-10-CM Official Guidelines for Coding and Reporting

Coding & Billing References

  • •
    ICD-10-CM Official Guidelines for Coding and Reporting

Frequently Asked Questions

What is the primary cause of otorrhagia?

Otorrhagia can be caused by various factors, including trauma, infections, or neoplastic processes affecting the ear. A thorough evaluation is necessary to determine the underlying cause.