Unsp injury of unspecified middle and inner ear, sequela

This code signifies a long-term or late effect resulting from an unspecified injury to an unspecified part of the middle or inner ear. This could include chronic hearing loss, persistent tinnitus, or balance issues that developed as a direct consequence of a past, unidentifiable ear trauma. The original injury itself is not specified, nor is the exact anatomical location within the middle or inner ear.

Apply this code when documentation clearly indicates a sequela (late effect) of a past, unspecified injury affecting the middle or inner ear, and the specific nature of the initial injury or the precise ear structure involved is unknown. This is appropriate when the patient presents for treatment of the residual condition, not the acute injury. Supporting documentation would include a history of ear trauma with current, related symptoms, but lacking details of the initial event.

• Always sequence the sequela code first, followed by codes for the specific residual condition(s) (e.g., tinnitus, hearing loss).
• Avoid using this code if the specific type of injury (e.g., barotrauma, blast injury) or the exact anatomical site (e.g., ossicles, cochlea) is documented; instead, use a more specific sequela code.
• Ensure the "S" seventh character is appropriate for a sequela; do not use for initial encounter (A) or subsequent encounter (D).