Unspecified cholesteatoma, unspecified ear

This code signifies a non-cancerous, cyst-like growth of skin cells in the middle ear or mastoid bone, where the specific type or location (e.g., congenital, acquired) is not documented. It can lead to hearing loss, discharge, and other ear-related symptoms due to its erosive nature.

Use this code when the medical record clearly indicates a diagnosis of cholesteatoma but lacks further specificity regarding its origin (e.g., congenital, acquired, primary, secondary) or the affected ear is not specified. This code is appropriate when documentation simply states "cholesteatoma" without additional details.

• Avoid using this code if the laterality (left, right, bilateral) is documented; instead, choose a more specific code.
• Do not use if the type of cholesteatoma (e.g., congenital, acquired) is specified; query the provider for clarification if needed.
• Always strive for greater specificity if available in the documentation to ensure accurate coding.