Recurrent cholesteatoma of postmastoidectomy cavity, bi ears

This code signifies the regrowth of a cholesteatoma within the mastoidectomy cavity in both ears, following a previous surgical removal. A cholesteatoma is an abnormal, noncancerous skin growth that can develop in the middle ear and mastoid bone, potentially leading to bone erosion and hearing loss. This recurrence indicates a persistent or re-established disease process in the surgical space.

Apply this code when documentation clearly indicates a cholesteatoma has reappeared in the mastoidectomy cavity of both the left and right ears. This typically follows a prior mastoidectomy procedure for cholesteatoma. Supporting documentation should include physician notes detailing the bilateral recurrence, often confirmed by imaging or otoscopic examination.

• Ensure documentation specifies "bilateral" involvement; otherwise, use the appropriate unilateral code.
• Distinguish between recurrent cholesteatoma and residual cholesteatoma; this code is for recurrence after complete removal.
• Code any associated complications (e.g., hearing loss, ossicular chain destruction) separately.