EHCS
Guest
Can I bill for an E/M and cerumen removal..if so, why....if not, why. For some reason it is such a grey line between being able to bill the e/m and the procedures at times. Can we choose to just bill the e/m if both shouldn't be billed? In this case the e/m would bring more revenue than just the cerumen removal and a full e/m was done. I have the same situation with 12001 laceration repairs, sometimes the e/m warrants a 99204 because of prescriptions given and extent of exam (which pays more than a 12001 laceration repair), but the main reason they are there is for laceration repair. I need some clarification.
vitals, HIP, CC all taken
Pt is a 47 yo male who is here with c/o right ear discomfort and rapid loss of hearing. No recent fever or illness.
REVIEW OF SYSTEMS:. Otherwise as stated above, a 14-point review of systems was conducted and negative.
General: Communicates without difficulty, well nourished, no acute distress.
Head: Normocephalic, no evidence injury, no tenderness, facial buttresses intact without stepoff.
Ears: EAC: Cerumen right, removed under microscopy, normal once cleared. TM: Intact, no fluid, mobile bilaterally.
Eyes: No scleral icterus, conjunctivae clear.
Neuro: CN II exam reveals vision grossly intact. No nystagmus at any point of gaze.
Nose: External evaluation reveals normal support and skin without lesions. Dorsum is intact. Anterior rhinoscopy reveals healthy pink mucosa over anterior aspect of inferior turbinates and intact septum. No purulence noted.
Oral: Oral cavity and oropharynx are intact, symmetric, without erythema or edema. Mucosa is moist without lesions.
Neck: Full range of motion without pain. There is no significant lymphadenopathy. No masses palpable.
DIAGNOSIS:
Impacted cerumen [380.4]
PROCEDURE: Cerumen removal
Cerumen removed using curette under microscopy with immediate restoration of hearing in patient.
DISCHARGE:.
Recommend following up with PCP or here for blood pressure recheck.
Return prn failure to improve.
vitals, HIP, CC all taken
Pt is a 47 yo male who is here with c/o right ear discomfort and rapid loss of hearing. No recent fever or illness.
REVIEW OF SYSTEMS:. Otherwise as stated above, a 14-point review of systems was conducted and negative.
General: Communicates without difficulty, well nourished, no acute distress.
Head: Normocephalic, no evidence injury, no tenderness, facial buttresses intact without stepoff.
Ears: EAC: Cerumen right, removed under microscopy, normal once cleared. TM: Intact, no fluid, mobile bilaterally.
Eyes: No scleral icterus, conjunctivae clear.
Neuro: CN II exam reveals vision grossly intact. No nystagmus at any point of gaze.
Nose: External evaluation reveals normal support and skin without lesions. Dorsum is intact. Anterior rhinoscopy reveals healthy pink mucosa over anterior aspect of inferior turbinates and intact septum. No purulence noted.
Oral: Oral cavity and oropharynx are intact, symmetric, without erythema or edema. Mucosa is moist without lesions.
Neck: Full range of motion without pain. There is no significant lymphadenopathy. No masses palpable.
DIAGNOSIS:
Impacted cerumen [380.4]
PROCEDURE: Cerumen removal
Cerumen removed using curette under microscopy with immediate restoration of hearing in patient.
DISCHARGE:.
Recommend following up with PCP or here for blood pressure recheck.
Return prn failure to improve.