Is this documentation enough to support 92567 with 99212?
History of Present Illness
Ear Follow-Up This child is seen for followup on otitis media. Seen for a checkup after completing her course of antibiotics. Mother reports no significant problems.
Current Medication
cefdinir
ibuprofen
Floxin otic
Allergy
No Known Drug Allergies.
Review of Systems
No other acute complaints. No interval changes since her last visit.
Vitals
Weight:63.10 lbs. Height:46.75 inches. Temperature temporal: 97.90 F
Physical Examination
Ears: No external deformities of the pinna. Repeat examination with the microscope showed canals to be free of swelling or discharge. The tympanic membranes are within normal limits and show no inflammation, retraction or middle ear effusion.
This is confirmed by tympanometry which shows good mobility and only a little bit of residual negative pressure. (This is the only documentation I see that it was even done)
Assessment and Plan
ICD: Eustachian Tube Dysfunction (381.81)
ICD: Acute Serous Otitis Media (381.01)
ICD: Acute Nasopharyngitis (460)
Assessment: We discussed the findings of today's examination with the help of the interpreter. She clears easily with antibiotics but still has a little residual eustachian tube dysfunction. This is probably what is making her prone to relapses. She is a borderline candidate for vent tube placement. Parents still expressed a desire to avoid surgery.
Plan: Since she has no residual fluid and hearing is unaffected I am okay with taking a wait and see approach but if she repeatedly requires broader spectrum antibiotic therapy then I may push the issue regarding vent tubes. They are to do everything they can to reduce her exposure to upper respiratory infections and mother was given an excuse so that the child can be kept inside during recess when it is cold outside. Followup prn.
History of Present Illness
Ear Follow-Up This child is seen for followup on otitis media. Seen for a checkup after completing her course of antibiotics. Mother reports no significant problems.
Current Medication
cefdinir
ibuprofen
Floxin otic
Allergy
No Known Drug Allergies.
Review of Systems
No other acute complaints. No interval changes since her last visit.
Vitals
Weight:63.10 lbs. Height:46.75 inches. Temperature temporal: 97.90 F
Physical Examination
Ears: No external deformities of the pinna. Repeat examination with the microscope showed canals to be free of swelling or discharge. The tympanic membranes are within normal limits and show no inflammation, retraction or middle ear effusion.
This is confirmed by tympanometry which shows good mobility and only a little bit of residual negative pressure. (This is the only documentation I see that it was even done)
Assessment and Plan
ICD: Eustachian Tube Dysfunction (381.81)
ICD: Acute Serous Otitis Media (381.01)
ICD: Acute Nasopharyngitis (460)
Assessment: We discussed the findings of today's examination with the help of the interpreter. She clears easily with antibiotics but still has a little residual eustachian tube dysfunction. This is probably what is making her prone to relapses. She is a borderline candidate for vent tube placement. Parents still expressed a desire to avoid surgery.
Plan: Since she has no residual fluid and hearing is unaffected I am okay with taking a wait and see approach but if she repeatedly requires broader spectrum antibiotic therapy then I may push the issue regarding vent tubes. They are to do everything they can to reduce her exposure to upper respiratory infections and mother was given an excuse so that the child can be kept inside during recess when it is cold outside. Followup prn.