Chronic serous otitis media, left ear

This code signifies a persistent, non-infectious inflammation of the middle ear in the left ear, characterized by the presence of thin, watery fluid behind the eardrum. This fluid accumulation is chronic, meaning it has been present for an extended period, typically three months or longer, without signs of acute infection.

Apply this code when documentation clearly indicates chronic serous otitis media affecting the left ear. This diagnosis is often made after otoscopic examination reveals a dull, retracted eardrum with fluid levels or bubbles, and the condition has persisted despite conservative management.

• Differentiate from acute serous otitis media (H65.02) or other forms of chronic otitis media (e.g., mucoid, suppurative).
• Ensure laterality (left ear) is explicitly documented; do not assume.
• If bilateral involvement is present, use the appropriate bilateral code (H65.23) or separate codes for each ear if laterality is specified.