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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