Otolaryngology Coding Alert

Question: The physician ordered an MRI and audio impedance test before reaching a diagnosis of subjective tinnitus and sensorineural hearing loss. What would be the medical risk/level of medical decision making for the diagnosis?

Mississippi Subscriber

Answer: You could typically count this as MDM (medical decision making) of moderate complexity due to the diagnostic testing the physician ordered. Symptoms that are diagnosed 388.31 (Subjective tinnitus) and 389.16 (Sensorineural hearing loss, asymmetrical) could be signs of an acoustic neuroma (225.1, Benign neoplasm of cranial nerves), which is probably why your physician ordered the MRI.

Without more information, as the scenario seems to meet the criteria of moderate risk. When you look at the Table of Risk, under “Presenting Problems” you will find “2 or more stable chronic illnesses” listed under Moderate Risk. This fits since the patient has subjective tinnitus and sensorineural hearing loss.