I see a lot of E/M visits with 92567- I don't think all of these that I have been running across are appropriate with a modifier 25 on the E/M. I thought if they are doing follow up visits with no concerns or new symptoms, then 92567 isn't really necessary- or is it? They are also scheduling these visits out for a 6 month follow up with 92567, again, with no symptoms. Here's another note for an example. Any thoughts from anyone? I just feel like it's wrong to bill out an E/M and also the testing when it doesn't seem necessary. Would it be appropriate to only bill 92567 if the physicians insist it be performed with no symptoms or concerns?
Chief Complaint: Follow-Up Tubes
History of Present Illness
Follow-Up Tubes She has been doing very well with her ventilation tubes placed back in November of 2011. She has had no recent issues with drainage or discomfort. No recent ear infections. No concerns regarding her health. No recent fevers or chills. We are monitoring the extrusion of these ventilation tubes
Past Medical History
Eustachian Tube Dysfunction since 12-17-2012
Born 8 Weeks Early; Twin
NICU x 5 Weeks
Denies Cardaic Issues
Denies Pulmonary Issues
Passed NBHS
Surgical History
Myringotomy with Tubes : 11/2011.
Family History
Non-contributory Family History.
Current Medication
No Known Current Medication
Allergy
No Known Drug Allergies.
Social History
Does Not Attend Daycare
Denies Smoke Exposure in the Home
Review of Systems
Constitutional Symptoms: She has normal appearance. Denies fever/sweats or loss of appetite/weight change. Allergies reviewed. Patient is generally healthy.
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: No diarrhea. Denies vomiting, painful/difficulty swallowing, heartburn/acid reflux, problems with bowel movements, constipation or nausea/vomiting. There is no abdominal pain. She does not experience dysphagia.
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 head injury, seizures, loss of balance, weakness or decrease in cognitive skills.
HEENT: Denies suffering from impaired hearing. Denies abnormal sneezing, sore throat, hoarse cry, 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:28.00 lbs. Height:36.00 inches. BMI: 15. Temperature temporal: 99.60 F
Physical Examination
General Appearance:
Patient is well-dressed and groomed and appears well in no acute distress, breathing easily.
Ear:
Right Ear Exam
Examination of right ear pinna reveals normal shape . Examination of right ear canal is within normal limits . Right tympanic membrane within normal limits . PE tube is present and patent in right ear. No effusion in right middle ear noted.
Left Ear Exam
Examination of left ear pinna reveals normal shape . Examination of left ear canal is within normal limits . Left tympanic membrane within normal limits . PE tube is present and patent in left ear. No effusion in left middle ear noted.
Nose:
External nose appearance is unremarkable. Nasal mucosa is healthy/unremarkable. There is no evidence of intranasal masses, lesions, or vascular abnormalities.
Nasal septum is generally midline. Turbinates are generally normal. On examination of nasal mucosa, there is no evidence of purulence, polyps, masses or lesions. Polyps : Absent. Lesions: Absent. Masses: Absent.
Oral Cavity:
Oral mucosa : Normal. Teeth : Normal. Lips: Normal. Gingiva: Normal. Floor of mouth : Normal. Tongue: Normal.
Oropharynx:
Mucosa: Normal. Palate: Normal. Base of tongue: Normal. Posterior pharynx: Normal.
Neck:
Inspection: Normal. Masses or lesions: Normal. Lymph nodes: Normal. Thyroid: Normal.
ENT
Audiology Services
Tests performed: Tympanometry.
Comments: Large Volume AU.
Assessment and Plan
ICD: Chronic Serous Otitis Media (381.10)
ICD: Eustachian Tube Dysfunction (381.81)
I am glad to see that she is doing well. There is no evidence of any serious extrusion of this time. There is also no evidence of any return of disease. We will continue to monitor her. I have suggested another visit in 6 months. She will be due for an audiogram at that time.
Follow up: 6 Months audiometric testing will be performed
Chief Complaint: Follow-Up Tubes
History of Present Illness
Follow-Up Tubes She has been doing very well with her ventilation tubes placed back in November of 2011. She has had no recent issues with drainage or discomfort. No recent ear infections. No concerns regarding her health. No recent fevers or chills. We are monitoring the extrusion of these ventilation tubes
Past Medical History
Eustachian Tube Dysfunction since 12-17-2012
Born 8 Weeks Early; Twin
NICU x 5 Weeks
Denies Cardaic Issues
Denies Pulmonary Issues
Passed NBHS
Surgical History
Myringotomy with Tubes : 11/2011.
Family History
Non-contributory Family History.
Current Medication
No Known Current Medication
Allergy
No Known Drug Allergies.
Social History
Does Not Attend Daycare
Denies Smoke Exposure in the Home
Review of Systems
Constitutional Symptoms: She has normal appearance. Denies fever/sweats or loss of appetite/weight change. Allergies reviewed. Patient is generally healthy.
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: No diarrhea. Denies vomiting, painful/difficulty swallowing, heartburn/acid reflux, problems with bowel movements, constipation or nausea/vomiting. There is no abdominal pain. She does not experience dysphagia.
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 head injury, seizures, loss of balance, weakness or decrease in cognitive skills.
HEENT: Denies suffering from impaired hearing. Denies abnormal sneezing, sore throat, hoarse cry, 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:28.00 lbs. Height:36.00 inches. BMI: 15. Temperature temporal: 99.60 F
Physical Examination
General Appearance:
Patient is well-dressed and groomed and appears well in no acute distress, breathing easily.
Ear:
Right Ear Exam
Examination of right ear pinna reveals normal shape . Examination of right ear canal is within normal limits . Right tympanic membrane within normal limits . PE tube is present and patent in right ear. No effusion in right middle ear noted.
Left Ear Exam
Examination of left ear pinna reveals normal shape . Examination of left ear canal is within normal limits . Left tympanic membrane within normal limits . PE tube is present and patent in left ear. No effusion in left middle ear noted.
Nose:
External nose appearance is unremarkable. Nasal mucosa is healthy/unremarkable. There is no evidence of intranasal masses, lesions, or vascular abnormalities.
Nasal septum is generally midline. Turbinates are generally normal. On examination of nasal mucosa, there is no evidence of purulence, polyps, masses or lesions. Polyps : Absent. Lesions: Absent. Masses: Absent.
Oral Cavity:
Oral mucosa : Normal. Teeth : Normal. Lips: Normal. Gingiva: Normal. Floor of mouth : Normal. Tongue: Normal.
Oropharynx:
Mucosa: Normal. Palate: Normal. Base of tongue: Normal. Posterior pharynx: Normal.
Neck:
Inspection: Normal. Masses or lesions: Normal. Lymph nodes: Normal. Thyroid: Normal.
ENT
Audiology Services
Tests performed: Tympanometry.
Comments: Large Volume AU.
Assessment and Plan
ICD: Chronic Serous Otitis Media (381.10)
ICD: Eustachian Tube Dysfunction (381.81)
I am glad to see that she is doing well. There is no evidence of any serious extrusion of this time. There is also no evidence of any return of disease. We will continue to monitor her. I have suggested another visit in 6 months. She will be due for an audiogram at that time.
Follow up: 6 Months audiometric testing will be performed