# question E/M level after post-op



## BABS37 (Jan 10, 2013)

I'm just curious. My provider wants to bill out a 99214-24 saying this visit isn't related to the patients previous surgery...42830-adenoidectomy...(90 day global) It seems like its a follow up but then not... any thoughts?


Reason For Visit: ear cleaning

Chief Complaint: Cerumen impaction
History of Present Illness


Cerumen impaction She has been doing well. There have been no concerns regarding her airway recently. She is having difficulty at night and she is scheduled for a repeat sleep study. We are here to discuss the reevaluation of the polyp that was found within the nasopharynx and also to remove the cerumen which accumulates on a regular basis.

Past Medical History
Cerumenosis since 10-10-2012.
Born 38 Weeks
NICU x 9 weeks
Failed NBHS; ABR completed
+ Hypertrophic Cardiomyopathy
+ Pulmonary Cardiac Stenosis
+Costello Syndrome

Surgical History
MDL/Bronch
BMTT

Family History
Non-contributory Family History.

Current Medication
propranolol
Claritin

Allergy
No Known Drug Allergies.

Vaccination History

Social History
Pediatric Social History: Child is in preschool.
Does Not Attend Daycare
Denies Smoke Exposure in the Home

Review of Systems
Constitutional Symptoms: Patient does not have normal appearance. Costello Syndrome Denies fever/sweats, fatigue, sleep disturbance, loss of appetite/weight change, malaise or recent weight changes. Allergies reviewed. Patient is generally healthy. There is no chills or night sweats.
Eyes: Eyes normal, no redness. No abnormal discharge from the eyes. Does not wear glasses. Denies visual changes.
Cardiovascular: Denies murmur. There is no shortness of breath or heart valve problems.
Respiratory: Denies cough, shortness of breath or wheezing. There is no asthma.
Gastrointestinal: Denies nausea, vomiting, painful/difficulty swallowing, Throat clearing, heartburn/acid reflux, problems with bowel movements, constipation or nausea/vomiting. No diarrhea. There is no abdominal pain. She does not experience dysphagia. There is no pain in the abdomen or stomach trouble.
Integumentary: Denies rashes, lesions, pigmentation changes, change in skin color or itching. There is no animal bite or scratch, hives or tick or insect bite.
Neurological: The child does not act differently. Denies ADHD, head injury, seizures, loss of balance, weakness or decrease in cognitive skills.
HEENT: Reports having impaired hearing. Denies abnormal sneezing, sore throat, hoarsness, ear pain, bleeding nose, nasal congestion, nasal discharge, oral ulcers, swollen glands in neck or ulcerations. She denies having postnasal drip. Does not have any oral or dental problems.
Endocrine: Denies glandular or hormone problem.
Hematologic/Lymphatic: hematologic/lymphatic : WNL. Denies lymph node enlargement/tenderness. There is no anemia. Denies getting bruises or bleeding easily.

Vitals
Weight:25.00 lbs. Temperature temporal: 98.10 F

Physical Examination
General Appearance:
Patient is well-dressed and groomed and appears well in no acute distress, breathing easily. The patient is not malnourished and exhibits a syndromic appearance. Obvious impairment is noted. She does not appear to be appropriately developed. Mental and emotional status is within normal limits.

Ears:
Auricles are normal. External auditory canal(s) are abnormal. copious cerumen
Oral Cavity:
Oral mucosa : Normal. Teeth : Normal. Lips: Normal. Gingiva: Normal. Floor of mouth : Normal. Tongue: Normal.

Neck/thyroid/lymph:
Inspection: Normal. Masses or lesions: Normal. Lymph nodes: Normal. Thyroid: Normal.

ENT

    Cerumen Removal


Cerumen was successfully removed with the aid of the microscope today. This was done with her mother's help. There was no evidence of any residual abnormality of the tympanic membranes. Landmarks were within normal limits.


Assessment and Plan
ICD: Cerumenosis (380.4)
She has done very well with cerumen removal today. This is a surprise given her previous behavior. The family is anxious to see how she does on the repeated thick study. Furthermore we will discuss a repeat nasopharyngoscopy to be performed in December. If there is any evidence of recurrence of the nasal polyp we will then consider further imaging and a second resection based upon the physical findings.


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## carolanntomko (Jan 10, 2013)

That level seems pretty high for an ear cleaning. Other than that, if it a separate illness/reason for visit other than what the surgery was for, then an office visit can be billed. But, ear cleanings, especially if it is Medicaid, are not always readily covered.


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## BABS37 (Jan 11, 2013)

Yes I agree- plus, these are templates for each patient encounter so it automatically uploads all history visits, med lists, prior history- which to me, makes it look like they actually spent a lot of time with the patient. Anyhow, I've been seeing this format on all of the "post-op" surgery visits and they want them coded out as an actually office visit and they are appending modifier 24. I just really disagree with this.


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