Acute suppr otitis media w spon rupt ear drum, right ear

This diagnosis code signifies an acute bacterial infection of the middle ear, specifically affecting the right ear, that has progressed to the point of causing a spontaneous perforation of the tympanic membrane. This rupture typically results in the drainage of purulent (pus-filled) material from the ear.

This code is appropriate for documenting cases of acute otitis media where the patient presents with a history and examination findings consistent with a sudden, non-traumatic perforation of the right eardrum, accompanied by signs of active infection. Documentation should clearly indicate the acute nature of the infection, the presence of suppuration, and the spontaneous rupture of the right tympanic membrane.

• Ensure documentation specifies "spontaneous rupture" to differentiate from traumatic perforations or those caused by myringotomy.
• Verify the laterality (right ear) is clearly documented; separate codes exist for left and bilateral involvement.
• Do not use this code if the rupture was iatrogenic (e.g., during a procedure) or due to trauma.