D23.9 - Other benign neoplasm of skin, unspecified

Clinical Definition

Otitis media is an infection or inflammation of the middle ear space. This condition is caused by fluid buildup behind the eardrum which can become infected, leading to pain, redness, and potential hearing difficulties.

Documentation Requirements

• Laterality (right, left, bilateral)

• Acuity (acute, chronic, recurrent)

• Type (suppurative, nonsuppurative)

• Presence/absence of tympanic membrane rupture

• If chronic, document duration (> 6 weeks)

• Associated symptoms (otalgia, fever, discharge)

• Cause if known (viral, bacterial, allergic)

• Any systemic symptoms

Common Synonyms

• Middle ear infection

• Ear infection

• "Water in the ear"

• "Swimmer's ear" (though this is incorrect - that's otitis externa)

Coding Conflicts

Excludes1:

• Otitis externa (H60.-)
  Excludes2:

• Acute myringitis (H73.0-)

• Eustachian tube disorders (H68-H69)

Scribing.io Automation

The AI scribe automatically detects and captures:

• Anatomical descriptors ("middle ear," "tympanic membrane")

• Temporal language indicating acuity ("ongoing for 2 months," "started yesterday")

• Symptom documentation ("purulent discharge," "ear pain")

• Physical exam findings ("bulging TM," "erythematous")

• Treatment plans including antibiotics and follow-up recommendations

These are mapped to appropriate ICD-10 codes based on specificity of documentation.