Granulation of postmastoidectomy cavity, unspecified ear

This code describes the presence of granulation tissue within the mastoidectomy cavity following a mastoidectomy procedure, where the specific ear affected is not documented. Granulation tissue is a common finding during the healing process but can sometimes indicate chronic inflammation or infection.

Use this code when documentation specifies granulation tissue in a post-mastoidectomy cavity without laterality (e.g., "granulation tissue in mastoidectomy cavity"). This code is appropriate when the physician's notes clearly indicate the presence of granulation tissue and do not specify whether it is in the right or left ear.

• Do not use this code if the laterality (right or left ear) is specified in the documentation; instead, use H95.121 or H95.122.
• Consider an additional code for any underlying infection (e.g., chronic otitis media) if documented.
• Ensure the documentation clearly states "granulation" and "postmastoidectomy cavity" to support this diagnosis.