Otitis media, unspecified, bilateral

This code signifies an inflammation of the middle ear, affecting both ears, where the specific type or cause of the otitis media is not documented. It indicates a general diagnosis of middle ear infection without further detail regarding its etiology (e.g., serous, suppurative, mucoid).

This code is appropriate when the provider's documentation clearly states "otitis media, bilateral" but does not specify the type of otitis media. It should be used when the physician has not identified whether the condition is acute, chronic, or recurrent, or the specific fluid present (e.g., serous, purulent).

• Avoid using this code if the documentation specifies the type of otitis media (e.g., acute suppurative, chronic serous); instead, use a more specific code from the H65 or H66 subcategories.
• Ensure the documentation explicitly states "bilateral" to support the fifth character "3". If only one ear is affected, use H66.91 (right ear) or H66.92 (left ear).
• If the laterality is not specified, but the type is unknown, consider querying the provider for clarification or using H66.90 (unspecified ear).