Beyond the Audiogram: A Clinician‘s Guide to the ICD‑10‑CM Hearing Loss Family

For the mental health clinician, hearing loss is rarely the first thing that comes to mind during a diagnostic workup. Yet the psychiatric presentations associated with auditory impairment are both common and frequently overlooked. Patients with untreated hearing loss have significantly higher rates of depression, anxiety, social withdrawal, and cognitive complaints—symptoms that are often attributed to a primary mood or anxiety disorder rather than to the unrecognized sensory deficit. For the clinician who treats the symptoms without interrogating their source, the consequence can be prolonged suffering, unnecessary medication trials, and missed opportunities for effective intervention.

In the 2026 fiscal year (October 1, 2025 – September 30, 2026), the ICD‑10‑CM classification of hearing loss has become more precise than ever. The addition of the H90.A‑ series has introduced unprecedented specificity for documenting hearing loss that affects both ears asymmetrically, while long‑standing codes for presbycusis, ototoxic damage, and sudden idiopathic hearing loss continue to provide important clinical distinctions.

This article moves beyond a simple list of codes. It provides a framework for understanding the pathophysiological classification of hearing loss (conductive vs. sensorineural vs. mixed), the laterality and asymmetry documentation requirements that auditors scrutinize, and the ancillary codes for hearing aids and cochlear implants that complete the clinical picture.

The Pathophysiological Triad – Conductive, Sensorineural, and Mixed

The ICD‑10‑CM classification of hearing loss is grounded in the underlying anatomy and physiology of the auditory system. Three fundamental types of hearing loss are recognised, each with distinct etiologies, treatment implications, and coding pathways.

Conductive Hearing Loss (H90.0‑, H90.1‑, H90.2)

Conductive hearing loss occurs when sound waves are prevented from travelling efficiently through the external ear canal or the middle ear to the cochlea. Common causes include cerumen impaction, otitis media with effusion, perforated eardrum, otosclerosis, and congenital malformations of the external or middle ear . Treatment may involve medication, surgery (e.g., stapedectomy for otosclerosis), conventional hearing aids, or bone‑conduction hearing devices.

In the ICD‑10‑CM system, conductive hearing loss is coded to the H90.0‑, H90.1‑, and H90.2‑ families, with laterality determining the specific code selection:

• H90.0: Conductive hearing loss, bilateral

• H90.1: Conductive hearing loss, unilateral with unrestricted hearing on the contralateral side (the opposite ear has normal hearing)

• H90.2: Conductive hearing loss, unspecified (use only when laterality cannot be determined)

• H90.A1‑: Conductive hearing loss with restricted hearing on the contralateral side (introduced in 2017)

Sensorineural Hearing Loss (H90.3‑, H90.4‑, H90.5)

Sensorineural hearing loss arises from damage to the cochlea (inner ear) or the auditory nerve. Causes include aging (presbycusis), noise exposure, ototoxic medications, head trauma, autoimmune disorders, tumours (e.g., vestibular schwannoma), and genetic factors . It can range from mild to profound deafness; treatment options include conventional hearing aids, middle ear implants, and cochlear implants.

ICD‑10‑CM codes for sensorineural loss follow a parallel structure:

• H90.3: Sensorineural hearing loss, bilateral

• H90.4: Sensorineural hearing loss, unilateral with unrestricted hearing on the contralateral side

• H90.5: Sensorineural hearing loss, unspecified (use only when laterality and type are not specified)

• H90.A2‑: Sensorineural hearing loss with restricted hearing on the contralateral side

H90.5 is a billable code that crosswalks to “Unspecified sensorineural hearing loss” and includes inclusion terms such as “central hearing loss NOS”, “congenital deafness NOS”, “neural hearing loss NOS”, and “sensory hearing loss NOS” . However, it carries important Excludes1 notes that preclude its use when a more specific diagnosis is known: “abnormal auditory perception (H93.2)”, “psychogenic deafness (F44.6)”, “deaf nonspeaking NEC (H91.3)”, “hearing loss NOS (H91.9)”, “noise‑induced hearing loss (H83.3)”, “ototoxic hearing loss (H91.0)”, and “sudden (idiopathic) hearing loss (H91.2)” .

Mixed Conductive and Sensorineural Hearing Loss (H90.6‑, H90.7‑, H90.8)

Mixed hearing loss occurs when both conductive and sensorineural pathology are present simultaneously. Common scenarios include a patient with chronic otitis media (conductive component) who also has age‑related presbycusis (sensorineural component). Treatment is tailored to the predominant cause and may combine medications, surgery, hearing aids, and cochlear implants .

Coding for mixed loss follows the same laterality framework:

• H90.6: Mixed conductive and sensorineural hearing loss, bilateral

• H90.7: Mixed conductive and sensorineural hearing loss, unilateral with unrestricted hearing on the contralateral side

• H90.8: Mixed conductive and sensorineural hearing loss, unspecified

• H90.A3‑: Mixed conductive and sensorineural hearing loss with restricted hearing on the contralateral side

An early 2026 update to the ICD‑10‑CM guidelines removed “mixed conductive and sensorineural hearing loss, unilateral” (H90.7) as a valid code for reimbursement. While H90.7 may still appear in some older resources, current coding practice requires using the more specific H90.71 (right ear involvement) or H90.72 (left ear involvement) with the appropriate laterality and contralateral hearing status. Both H90.71 and H90.72 remain non‑billable parent codes, requiring further specification to the 7‑character level (e.g., H90.71 for mixed loss in the right ear with unrestricted contralateral hearing) .

Laterality – The Dimension That Determines the Code

The single most common coding error in hearing loss documentation is the failure to specify laterality. ICD‑10‑CM includes distinct code families for bilateral, unilateral with unrestricted contralateral hearing, unilateral with restricted contralateral hearing, and unspecified presentations. Choosing the wrong laterality code is not a minor error; it triggers audit flags and may result in claim denials.

Bilateral Hearing Loss (H90.0, H90.3, H90.6)

Audiologists should code a specific type of hearing loss for each ear when bilateral hearing loss is present. For symmetrical bilateral sensorineural loss, the appropriate code is H90.3 (Sensorineural hearing loss, bilateral). However, for asymmetrical sensorineural hearing loss, a different coding strategy is required. The audiology coding guidance states that “asymmetrical sensorineural hearing loss is reported using H90.3 (sensorineural hearing loss, bilateral)” because ICD‑10‑CM lacks specific codes for each ear when both ears are affected but to different degrees . In such cases, the clinical documentation should describe the asymmetry in the narrative note (e.g., “right ear thresholds 20 dB worse than left ear”), but the code remains H90.3.

Unilateral Hearing Loss with Unrestricted Contralateral Hearing

When one ear has hearing loss and the opposite ear has normal hearing (defined as thresholds within normal limits), the appropriate code family uses the .1 (for conductive), .4 (for sensorineural), or .7 (for mixed) series, with the laterality further specified by the fifth character:

• H90.11: Conductive hearing loss, unilateral, right ear, with unrestricted hearing on the contralateral side

• H90.12: Conductive hearing loss, unilateral, left ear, with unrestricted hearing on the contralateral side

• H90.41: Sensorineural hearing loss, unilateral, right ear, with unrestricted hearing on the contralateral side

• H90.42: Sensorineural hearing loss, unilateral, left ear, with unrestricted hearing on the contralateral side

• H90.71: Mixed conductive and sensorineural hearing loss, unilateral, right ear, with unrestricted hearing on the contralateral side

• H90.72: Mixed conductive and sensorineural hearing loss, unilateral, left ear, with unrestricted hearing on the contralateral side

Unilateral Hearing Loss with Restricted Contralateral Hearing (The H90.A‑ Family)

The most significant recent addition to the hearing loss coding family is the H90.A‑ series (Conductive and sensorineural hearing loss with restricted hearing on the contralateral side), introduced in 2017. These codes are used when one ear has a hearing loss and the opposite ear also has hearing loss, but the loss is milder or less severe – not normal hearing. The “restricted” designation signals that the contralateral ear is not normal; it is simply less impaired .

Within this family, the codes are organised by the type of hearing loss in the affected ear, with the right and left ear laterality specified:

• H90.A11: Conductive hearing loss, right ear, with restricted hearing on the contralateral side

• H90.A12: Conductive hearing loss, left ear, with restricted hearing on the contralateral side

• H90.A21: Sensorineural hearing loss, right ear, with restricted hearing on the contralateral side

• H90.A22: Sensorineural hearing loss, left ear, with restricted hearing on the contralateral side

• H90.A31: Mixed conductive and sensorineural hearing loss, right ear, with restricted hearing on the contralateral side

• H90.A32: Mixed conductive and sensorineural hearing loss, left ear, with restricted hearing on the contralateral side

These codes are billable and have become the standard for documenting asymmetric hearing loss without a normal ear to serve as a reference.

Specific Hearing Loss Conditions – Presbycusis, Ototoxic Loss, and Sudden Deafness

Beyond the general H90 and H91 categories, several specific hearing loss conditions have their own dedicated codes, each with distinct clinical and coding implications.

Presbycusis – Age‑Related Hearing Loss (H91.10‑H91.13)

Presbycusis is the gradual, bilateral, high‑frequency hearing loss that occurs as part of the normal aging process. It typically begins in the third or fourth decade and worsens progressively. The majority of adults over 60 years have some degree of presbycusis .

In ICD‑10‑CM, presbycusis is coded to the H91.1‑ series, which supports separate codes for right ear (H91.11), left ear (H91.12), bilateral (H91.13), and unspecified (H91.10) presentations. Importantly, the clinical documentation should specify the degree of loss (mild, moderate, severe, profound) and the impact on communication to support medical necessity for hearing aids or cochlear implants.

Ototoxic Hearing Loss (H91.0‑)

Ototoxic hearing loss is caused by medications that damage the cochlea or the auditory nerve, including aminoglycoside antibiotics, platinum‑based chemotherapy (cisplatin, carboplatin), loop diuretics, and high‑dose aspirin. The hearing loss may be reversible or permanent, depending on the agent and duration of exposure.

The ICD‑10‑CM code family is H91.0‑ (Ototoxic hearing loss). Importantly, a Code First note directs the coder to sequence the poisoning due to drug or toxin (T36‑T65 with fifth or sixth character 1‑4) as the primary diagnosis, with H91.0‑ as the manifestation code . A Use Additional note also permits coding the adverse effect when applicable, using T36‑T50 with fifth or sixth character 5. For the mental health clinician prescribing psychotropic medications with ototoxic potential (e.g., certain antidepressants or mood stabilisers), this coding nuance is essential for documenting iatrogenic harm and justifying changes in pharmacotherapy.

Sudden Idiopathic Hearing Loss (H91.2‑)

Sudden sensorineural hearing loss (SSNHL) is defined as a rapid‑onset, unexplained hearing loss, typically occurring over less than 72 hours. It is an otologic emergency, as early treatment with corticosteroids may improve outcomes. The code H91.2‑ (Sudden idiopathic hearing loss) is used when no specific aetiology has been identified .

For mental health clinicians, sudden hearing loss may present as a primary complaint or as a complication of an underlying autoimmune or vascular condition. When the hearing loss is associated with a known cause (e.g., Menière‘s disease, autoimmune inner ear disease), the specific disease code (H81.0‑, H90.‑, etc.) should be used instead of H91.2.

Congenital Hearing Loss (H90.‑ with appropriate laterality and Q-codes for malformations)

Hearing loss present at birth may be conductive (due to congenital malformations of the external or middle ear), sensorineural (due to genetic syndromes, intrauterine infections, or developmental anomalies), or mixed. In ICD‑10‑CM, the type of hearing loss is coded with H90.‑ as described, and the congenital malformation is coded separately with a Q‑code (e.g., Q16.0 for congenital absence of the external auditory canal). When the newborn hearing screening is abnormal but the definitive diagnosis is not yet established, the appropriate code is P09.6 (Abnormal findings on neonatal hearing screening) .

Ancillary Codes – Hearing Aids, Cochlear Implants, and Screening Encounters

For the comprehensive management of hearing‑impaired patients, ICD‑10‑CM includes a series of Z‑codes that capture the use of assistive devices and the reason for encounter.

• Z97.4: Presence of external hearing aid. Use this as a secondary code when the patient uses a conventional hearing aid, documenting that the device is currently in use.

• Z46.1: Encounter for fitting and adjustment of hearing aid. This code is used when the primary reason for the visit is to adjust, repair, or fit a hearing aid, not to evaluate the underlying hearing loss .

• Z01.10‑Z01.118: Encounter for hearing examination. These codes are used for routine hearing screening or diagnostic evaluation when no active pathology is documented.

• Z82.2: Family history of deafness and hearing loss. Use this as a secondary code when the patient has a first‑degree relative with hearing impairment.

For cochlear implant recipients, the appropriate codes for device‑related encounters include Z96.22 (Presence of cochlear implant) and, for the associated rehabilitation services, code the underlying hearing loss (e.g., H90.3 for bilateral sensorineural loss) followed by the appropriate CPT code for audiological rehabilitation.

Documentation and Audit Risk

Auditors and third‑party payers scrutinise hearing loss claims for several specific elements. The table below summarises the most common audit flags and the corresponding mitigation strategies.

When using unspecified codes such as H91.90 (Hearing loss, unspecified), the documentation must clearly justify why a more specific code cannot be assigned. Possible justifications include “audiogram inconclusive for specific type or laterality” or “patient unable to complete diagnostic testing”. The audit risk for unspecified codes is high, and payers may deny claims if they are used repeatedly without documentation of the clinical obstacles that prevent specificity .

For patients receiving initial evaluation of a hearing problem, testing is typically covered without prior authorisation. For subsequent evaluations, the medical record must clearly document the medical necessity—for example, “worsening of hearing loss”, “new tinnitus”, “change in hearing aid prescription”, or “monitoring of ototoxic medication”.

FAQ

How do I code asymmetrical sensorineural hearing loss?

ICD‑10‑CM lacks separate codes for each ear when both ears are affected but to different degrees. The correct approach is to use H90.3 (Sensorineural hearing loss, bilateral) and document the asymmetry in the clinical narrative. For example: “Right ear thresholds 20 dB worse than left ear at 4 kHz.” Do not use H90.4 (unilateral) for the worse ear, as that would incorrectly imply normal hearing in the contralateral ear .

What is the difference between “unrestricted” and “restricted” hearing on the contralateral side?

“Unrestricted” means the contralateral ear has normal hearing (thresholds within normal limits). “Restricted” means the contralateral ear also has hearing loss, but the loss is less severe than in the affected ear. This distinction determines whether you use the traditional H90.1/4/7 series (unrestricted) or the newer H90.A series (restricted) .

Can I use H90.0 for bilateral conductive hearing loss when the patient also has presbycusis?

No. H90.0 is reserved for pure conductive hearing loss. If the patient has bilateral conductive loss and age‑related sensorineural loss, the correct code is H90.6 (Mixed conductive and sensorineural hearing loss, bilateral). Using H90.0 in this scenario would imply that the sensorineural component is absent, which may affect treatment decisions and reimbursement.

What documentation is required to support a code for ototoxic hearing loss (H91.0‑)?

The record must document: (1) the causative medication (e.g., cisplatin, gentamicin), (2) the temporal relationship between drug exposure and the onset of hearing loss, (3) audiometric confirmation of the loss, and (4) the laterality and severity. In addition, the poisoning due to drug or toxin code (T36‑T65) must be sequenced first, followed by H91.0‑ as the manifestation code .

How do I code a patient who reports hearing difficulties but has a normal audiogram?

When the patient’s subjective complaint of hearing difficulty is not confirmed by objective audiometric testing, the appropriate code is H93.2 (Other abnormal auditory perceptions), not a hearing loss code. This code also encompasses auditory processing disorders (H93.25) and may be used while a diagnostic workup for central auditory processing disorder is underway . Do not assign a code from H90.‑ in the absence of audiometric confirmation of peripheral hearing loss.

Conclusion

The ICD‑10‑CM hearing loss family is more than a list of codes; it is a structured language for communicating the location, type, laterality, and severity of auditory impairment. For the mental health clinician, familiarity with these codes is essential for recognising when a patient’s depression, anxiety, or social withdrawal may be secondary to an undiagnosed sensory deficit. A patient with untreated presbycusis, for example, may present with classic symptoms of major depression—anhedonia, social isolation, fatigue—that resolve not with an antidepressant, but with a properly fitted hearing aid.

The system is precise: conductive loss goes to H90.0‑2‑, sensorineural to H90.3‑5‑, mixed to H90.6‑8‑. Laterality is not optional; it is the dimension that determines the code. The newer H90.A‑ family has provided long‑needed specificity for patients whose hearing loss affects both ears but with asymmetrical severity. The ancillary Z‑codes for hearing aids and cochlear implants ensure that the full clinical picture is captured. And the “golden thread” of documentation—clear laterality, type, severity, and medical necessity—remains the clinician’s strongest defence against audits.

The code you assign is the patient’s clinical story, told in the language that insurers, regulators, and other providers understand. Tell it clearly. Tell it completely. And let it guide the care that restores not only hearing, but connection.

References

1. ICD‑10 Data. (2026). 2026 ICD‑10‑CM Diagnosis Code H90.A2 – Sensorineural hearing loss, unilateral, with restricted hearing on the contralateral side.

2. ICD‑10 Data. (2026). 2026 ICD‑10‑CM Codes H90: Conductive and sensorineural hearing loss*.

3. ICD‑10 Data. (2026). 2026 ICD‑10‑CM Diagnosis Code H91 – Other and unspecified hearing loss.

4. AAPC. (2025). Listen to This Ear Condition Coding Advice, Part 2: Otolaryngology Coding.

5. S10.ai. (n.d.). Bilateral Hearing Loss – AI‑Powered ICD‑10 Documentation.

6. AAPC. (n.d.). ICD‑10 Code for Unspecified sensorineural hearing loss – H90.5.