ICD-10 Code A18.6 | Tuberculosis of (inner) (middle) ear Symptoms, Diagnosis, Billing

Tuberculosis of the inner or middle ear is a rare but serious condition caused by Mycobacterium tuberculosis. It can lead to significant complications, including hearing loss and chronic ear infections. Accurate coding with ICD-10 Code A18.6 is essential for proper diagnosis, documentation, medical billing, and public health reporting, ensuring that healthcare providers can track and manage this infectious disease effectively.

What is ICD-10 Code A18.6 for Tuberculosis of (inner) (middle) ear?

ICD-10 Code A18.6 specifically denotes Tuberculosis of the inner or middle ear, a manifestation of systemic tuberculosis. This code should be utilized when documenting cases where the ear is affected, often as a complication of pulmonary or extrapulmonary tuberculosis, ensuring accurate billing and clinical management.

ICD-10 Code A18.6 – Clinical Definition and Explanation of Tuberculosis of (inner) (middle) ear

Tuberculosis of the inner or middle ear is primarily caused by the spread of Mycobacterium tuberculosis from other infected sites, such as the lungs. This condition can progress to severe complications, including hearing impairment and chronic infections, necessitating prompt medical intervention.

Key Clinical Features:

• Presence of ear pain or discomfort.
• Hearing loss, which may be conductive or sensorineural.
• Discharge from the ear, potentially purulent.
• History of systemic tuberculosis or exposure to infected individuals.

ICD-10 Code A18.6 for Tuberculosis of (inner) (middle) ear – SOAP Notes & Clinical Use

In SOAP notes, ICD-10 Code A18.6 is utilized to document the diagnosis of Tuberculosis of the inner or middle ear, aiding in the assessment of symptoms, clinical findings, and treatment plans. This code is relevant in both acute and chronic care settings, ensuring comprehensive patient management.

What Does ICD-10 Code A18.6 for Tuberculosis of (inner) (middle) ear Mean in SOAP Notes?

ICD-10 Code A18.6 connects subjective patient-reported symptoms and objective clinical findings to a formal diagnosis of Tuberculosis of the inner or middle ear. This code is crucial for ensuring continuity of care, supporting accurate billing, and meeting EHR documentation standards.

Treatment Options for ICD-10 Code A18.6 – Tuberculosis of (inner) (middle) ear

The management of Tuberculosis of the inner or middle ear requires urgent medical attention, often necessitating hospitalization for effective treatment.

Antibiotic Therapy:

• First-line: Isoniazid and Rifampin for a duration of 6-12 months.
• Alternative: Ethambutol or Pyrazinamide may be considered based on susceptibility.
• Monitor for drug interactions and side effects.

Supportive Care:

• Pain management with analgesics.
• Regular audiological assessments to monitor hearing loss.
• Counseling on the importance of adherence to therapy.

Infection Control:

• Implement standard precautions to prevent transmission.
• Isolation may be necessary in cases of active pulmonary tuberculosis.
• Educate patients on respiratory hygiene.

How to Document Symptoms of Tuberculosis of (inner) (middle) ear (ICD-10 A18.6) in SOAP Notes

Subjective:

• Patient reports ear pain and a sensation of fullness.
• History of recent upper respiratory infection.
• Notable hearing loss over the past few weeks.
• Discharge from the ear described as yellow and foul-smelling.

Objective:

• Auscultation reveals normal respiratory sounds.
• Otoscopy shows redness and swelling of the tympanic membrane.
• Audiometry indicates moderate conductive hearing loss.
• Vital signs: Temperature 100.4°F, Pulse 88 bpm, Respiratory rate 16.

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SOAP Note Guidelines for Diagnosing Tuberculosis of (inner) (middle) ear (ICD-10 Code A18.6)

Assessment:

• Diagnosis: Tuberculosis of the middle ear, moderate severity.
• ICD-10 Code: A18.6.
• Contributing factors: Recent history of pulmonary tuberculosis.
• Consider differential diagnoses such as chronic otitis media.

Plan:

• Initiate first-line antibiotic therapy: Isoniazid and Rifampin.
• Schedule follow-up audiology appointment in 4 weeks.
• Educate patient on medication adherence and potential side effects.
• Monitor for signs of treatment response and complications.

Treatment & Plan Section for ICD-10 Code A18.6 – Tuberculosis of (inner) (middle) ear

• First-line pharmacologic treatment includes Isoniazid and Rifampin.
• Non-pharmacologic strategies involve patient education on adherence.
• Regular monitoring of hearing function and treatment response.
• Follow-up appointments to assess progress and adjust treatment as necessary.

Using ICD-10 Code A18.6 for Tuberculosis of (inner) (middle) ear in Billing & SOAP Note Compliance

• Select accurate subcodes based on clinical severity or complications.
• Document symptoms clearly under Subjective (S) and Objective (O) in SOAP notes.
• Ensure treatment plans align with clinical guidelines to support justified billing.
• Commonly billed CPT codes include 99213 for established patient office visits.

Related ICD-10 Codes Often Used with Tuberculosis of (inner) (middle) ear

• A15.0 – Pulmonary tuberculosis, bacteriologically and histologically confirmed
• A18.0 – Tuberculosis of bones and joints
• A18.1 – Tuberculosis of meninges
• A18.2 – Tuberculosis of the genitourinary system

ICD-10 Code A18.6 in Medical Billing and Insurance for Tuberculosis of (inner) (middle) ear

ICD-10 Code A18.6 is critical for accurate billing in hospital, ER, or infectious disease care settings.

Billing Notes:

• Ensure thorough documentation of symptoms and treatment plans.
• Use this code in conjunction with relevant CPT codes for comprehensive billing.
• Include key chart elements such as patient history and treatment response.

Common CPT Pairings: