Chronic serous otitis media, unspecified ear

This code represents a persistent, non-infectious inflammation of the middle ear characterized by the presence of serous (thin, watery) fluid behind the eardrum. It indicates a chronic condition without specifying laterality.

Apply this code when documentation confirms chronic serous otitis media, often referred to as "glue ear," and the specific ear affected (right, left, or bilateral) is not documented. This diagnosis is typically made based on otoscopic examination showing fluid and often a retracted or dull tympanic membrane, along with a history of persistent symptoms.

• Do not use this code if the laterality (right, left, or bilateral) is specified in the medical record; instead, choose the more specific code.
• Distinguish from acute serous otitis media (H65.0-) or other forms of chronic otitis media (e.g., mucoid, sanguinous).
• Ensure documentation clearly states "chronic" and "serous" to support this specific diagnosis.