Acute suppr otitis media w spon rupt ear drum, recur, r ear

This code signifies a recurring, acute bacterial infection of the middle ear in the right ear, characterized by pus formation and a spontaneous perforation of the eardrum. The spontaneous rupture indicates that the pressure from the infection caused the tympanic membrane to tear without surgical intervention.

Apply this code when documentation clearly indicates a diagnosis of acute suppurative otitis media affecting the right ear, with a history of previous similar episodes (recurrent), and a spontaneous perforation of the tympanic membrane is observed. This code is appropriate when the physician explicitly states "recurrent" or provides a history of multiple acute episodes.

• Differentiate between spontaneous rupture and a surgically induced myringotomy; this code is only for spontaneous events.
• Ensure documentation specifies "recurrent" to justify the fifth character '4'; otherwise, a non-recurrent code may be more appropriate.
• Confirm laterality (right ear) is clearly documented to avoid miscoding with left or bilateral ear involvement.