Acute mastoiditis without complications, right ear

This code represents an acute inflammatory process affecting the mastoid air cells of the right temporal bone. It is characterized by infection and inflammation without evidence of intracranial or extracranial spread, such as facial nerve paralysis, labyrinthitis, or abscess formation.

Assign this code when documentation clearly indicates a new onset of mastoiditis in the right ear, and specifically states that no complications are present. Supporting documentation would include physician notes detailing symptoms like postauricular pain, swelling, erythema, and fever, along with a confirmed diagnosis of acute mastoiditis without mention of complications.

• Ensure the documentation explicitly states "without complications" to differentiate from codes for mastoiditis with complications.
• Verify laterality (right ear) is clearly documented; separate codes exist for left and bilateral involvement.
• Do not use this code if there is any mention of facial paralysis, intracranial extension, or other complications, as more specific codes would then apply.