Chronic mucoid otitis media, unspecified ear

This code describes a persistent, non-purulent inflammation of the middle ear characterized by the presence of thick, mucus-like fluid behind the eardrum. It indicates a chronic condition where the specific ear (left or right) affected is not documented.

Use this code when documentation indicates a diagnosis of chronic mucoid otitis media without specifying laterality. This diagnosis is typically supported by otoscopic examination revealing a dull, retracted, or bulging tympanic membrane with fluid, often accompanied by hearing loss.

• Do not use this code if the laterality (right, left, or bilateral) is specified in the medical record; instead, select a more specific code from the H65.3 series.
• Distinguish from acute otitis media (H65.0-H65.2) or serous otitis media (H65.2-).
• Always query the provider for laterality if not documented to ensure the most specific code is assigned.