Wiki Can I Bill for a New Patient Office Visit and Hearing Test?

[PLDalsoren]

Good Morning,
One of our providers (ENT specialist) saw a new patient to establish care. The only complaint the patient had per the visit note was hearing loss. The doctor did an exam and ordered a hearing test which was done in office. The results were low normal hearing loss. He counseled the patient to protect her ears and avoid lout noises as much as possible. Return in one year if needed. He wants to bill a new patient E/M and for the hearing test (92553). We are having discussion about this in the office on whether or not an E/M code is supported. It's a new patient so it seems like he should get credit for the exam but the only problem addressed was the hearing loss and that would be billed with the hearing test. I didn't think there was any billable ICD10 code for establishing care either. I would appreciate any insight on this as I would need to go back to the provider to explain why or why not he can bill for an E/M visit and a hearing test. Thank you!

 

[thomas7331]

A hearing test isn't a surgical procedure, it's a diagnostic test, so it doesn't subject the E/M to the same global package as would a minor procedure. There's nothing incorrect about reporting and E/M code for the physician's work in evaluating and managing the new problem. 'Establishing care' does not support medical necessity, but if the physician is evaluating the patient, reviewing the results of the hearing test, and making recommendations to the patient about the problem, then that is work that can and should be reported by assigning the appropriate E/M level.