AHA Coding Clinic® for ICD-10-CM and ICD-10-PCS - 2021 Issue 3; Ask the Editor
Cholesteatoma in Aditus Ad Antrum
The patient presents for treatment of cholesteatoma of the left ear, which is filling the aditus ad antrum, the attic area and extends into the mastoid. When cholesteatoma is present in more than one site, is each site coded separately, or should this be interpreted as diffuse cholesteatosis? Must the provider document “diffuse” in order for this condition to be assigned to the code for diffuse cholesteatosis? ...
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Article Overview
This article addresses ICD-10-CM coding for cholesteatoma affecting multiple sites in the left ear, including discussion of how the condition is characterized when it extends through adjacent ear structures. It is aimed at coders and other revenue cycle professionals who need to understand the article’s site-based coding guidance and how the guidance relates to documentation language and diagnosis classification.
Why This Topic Matters
Correctly identifying the relevant cholesteatoma site coding approach can affect diagnosis reporting accuracy and clinical data quality for ear, nose, and throat cases. The article is useful for professionals reviewing documentation that references several contiguous anatomic locations within the ear.
What You Will Learn
- How the article frames cholesteatoma involving more than one ear site
- How the guidance relates to ICD-10-CM site-based diagnosis reporting
- What documentation concepts are discussed in relation to multi-site ear disease
- How the discussion applies to left-ear cholesteatoma cases
Who Should Read This
- Medical coders
- Coding educators
- Auditors
- Revenue cycle staff
- ENT billing specialists
Codes Discussed
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