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Question: One of our providers diagnosed a patient with an acute recurrent abscess of the right middle ear resulting in perforation of the central eardrum. I can’t find a diagnosis code for a middle ear abscess, so do I use H65.01 with H72.01?

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Answer: Coding this condition with two codes, H65.01 (Acute serous otitis media, right ear) and H72.01 (Central perforation of tympanic membrane, right ear), would be incorrect.

Here’s why.

If you go to the ICD-10-CM Index to Diseases and Injuries and look up abscess ⇒ ear (middle) you are instructed to see also Otitis, media, suppurative. This directs you to the H66.0- (Acute suppurative otitis media) codes, which are divided into two sets of combination codes: H66.00- (Acute suppurative otitis media without spontaneous rupture of ear drum) and H66.01- (Acute suppurative otitis media with spontaneous rupture of ear drum). These codes are further divided into codes for nonrecurrent and recurrent conditions, which makes H66.014 (Acute suppurative otitis media with spontaneous rupture of ear drum, recurrent, right ear) the correct code for the diagnosis.

Know This Guideline and Alphabetic Index Definition to Confirm

ICD-10-CM Official Guideline I.B.9 tells you, “A combination code is a single code used to classify … a diagnosis with an associated complication.” So, since the provider has documented that the middle ear abscess resulted in perforation of the patient’s eardrum, you can feel safe in assigning the combination code.

A second method to check the code’s accuracy is to make sure the words “rupture” and “perforation” are synonymous with each other. In the case of eardrums, simply look up Rupture, ruptured ⇒ ear drum (nontraumatic) in the ICD-10-CM Index to Diseases and Injuries, which leads you to see also Perforation, tympanum.

With this evidence, you can feel comfortable using H66.014 to describe an acute recurrent abscess of the right middle ear resulting in perforation of the central eardrum.

Bruce Pegg, BA, MA, CPC, CFPC, Managing Editor, AAPC