Cholesteatoma coding in ICD-10-CM
Proper cholesteatoma coding should include the specific site as well as the side of the body.
Cholesteatoma is an abnormal skin growth in the middle ear, behind the eardrum. These develop as cysts or pouches that fill with old skin cells and other waste material. Typically, a cholesteatoma occurs because of Eustachian tube dysfunction, as well as infection in the middle ear, and can lead to deafness. Dorlands Medical Dictionary defines a cholesteatoma as a cyst-like mass or benign tumor with a lining of stratified squamous epithelium, usually of keratinizing type, filled with desquamating debris frequently including cholesterol.
There are two types of cholesteatoma:
? Acquired cholesteatoma is the most common. It is caused by accumulation of keratin in a pouch of tympanic membrane extending into the middle ear space. Cholesteatoma may also result from trauma, or metaplasia of the middle ear mucosa (metaplasia is the replacement of one differentiated cell type with another mature differentiated cell).
? Congenital cholesteatoma are most commonly found in the anterior aspect of the eardrum.
Good clinical documentation should include the specific site or location of the Cholesteatoma such as:
? Attic. H71.0 Cholesteatoma of attic
? Tympanum. H71.1 Cholesteatoma of Tympanium.
? Mastoid.H71.2 Cholesteatoma of mastoid.
? External ear.H60.4 Cholesteatoma of external ear.
ICD-10-CM introduces the concept of laterality, and complete documentation should detail whether the Cholesteatoma is left, right, or bilateral. If laterality is not documented, an unspecified code must be used.
Additionally, category H71 contains an Excludes II note, which indicates that the presence of additional conditions, when present can be reported separately.
Excludes II:
Cholesteatoma of external ear (H60.4-)
Recurrent cholesteatoma of postmastiodectomy cavity (H95.0-)