Chronic allergic otitis media, unspecified ear

This code signifies a persistent inflammatory condition of the middle ear, specifically triggered by an allergic reaction, where the affected ear is not specified. It involves chronic fluid accumulation or inflammation behind the eardrum due to an allergic response, rather than infection.

Use this code when documentation clearly indicates chronic otitis media with an allergic etiology, and the laterality (left or right ear) is not documented. Supporting documentation would include physician notes detailing allergic triggers, chronic symptoms like hearing loss or ear fullness, and findings consistent with middle ear inflammation without acute infection.

• Ensure documentation explicitly states "allergic" as the cause of the chronic otitis media; otherwise, a non-allergic chronic otitis media code may be more appropriate.
• Avoid using this code if the laterality (left or right ear) is specified; instead, select the more specific code for the affected ear (H65.411 for right, H65.412 for left).
• Always query the provider for clarification if "allergic" is suspected but not explicitly documented, or if laterality is missing.