Hi. I have an example of what I feel is an issue and I see this day in and day out. Can someone give me some insight or guidance on this? My problem is, there is no CC or really any reason given as to why the patient is being seen other than a previous note dated 03/05/14 that says the patient will be in a for a follow up due to cerumen impaction. My physician wants to bill 99213 and 69210. I think only the 69210 is appropriate. Thoughts?
DOS 08/04/14
History of Present Illness
Follow-Up Tubes
Tympanostomy tube placement was performed 12-11-2013 . No drainage reported. No pain is reported. There is no discomfort. No hearing loss reported. No post op complications reported. No fever.
She has done well with her ventilation tubes. There have been no active issues.
Current Medication
amoxicillin
CIPRODEX
Allergy
No Known Drug Allergies.
Review of Systems
Constitutional Symptoms: She has normal appearance. Denies fever/sweats, sleep disturbance, loss of appetite/weight change, chills, fatigue, malaise or recent weight changes. Allergies reviewed. Patient is generally healthy. No night sweats.
Respiratory: Denies cough, shortness of breath or wheezing.
HEENT: Denies suffering from impaired hearing. Denies abnormal sneezing, sore throat, hoarsness, 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.
Vitals
Weight:24.50 lbs. Height:31.00 inches. Temperature temporal: 97.80 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 obstructed with cerumen .
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 anterior examination of the nose, there is no evidence of purulence, polyps, masses or lesions. Polyps : Absent. On anterior exam.
Mucosa: Normal. Palate: Normal. Base of tongue: Normal. Posterior pharynx: Normal.
Inspection: Normal. Masses or lesions: Normal. Lymph nodes: Normal.
Thyroid: Normal.
ENT
Cerumen Removal Right cerumenectomy is performed under the operating microscope. A curette was used to clean the canal of material. Findings following the cerumenectomy demonstrate Right tube in place and patent with normal surrounding TM The patient tolerated this procedure well without trauma to the canal or tympanic membrane.
ICD: Chronic Serous Otitis Media (381.10)
ICD: Ceruminosis (380.4)
ICD: Eustachian Tube Dysfunction (381.81)
ICD: Chronic Mucoid Otitis Media (381.20)
ICD: Unspecified Acute Nonsuppurative Otitis Media (381.00)
Once the cerumen was removed we were able to identify the right ventilation tube. There is no evidence of extrusion at this time. We will see her back in 6 months at which time we will test her hearing.
DOS 08/04/14
History of Present Illness
Follow-Up Tubes
Tympanostomy tube placement was performed 12-11-2013 . No drainage reported. No pain is reported. There is no discomfort. No hearing loss reported. No post op complications reported. No fever.
She has done well with her ventilation tubes. There have been no active issues.
Current Medication
amoxicillin
CIPRODEX
Allergy
No Known Drug Allergies.
Review of Systems
Constitutional Symptoms: She has normal appearance. Denies fever/sweats, sleep disturbance, loss of appetite/weight change, chills, fatigue, malaise or recent weight changes. Allergies reviewed. Patient is generally healthy. No night sweats.
Respiratory: Denies cough, shortness of breath or wheezing.
HEENT: Denies suffering from impaired hearing. Denies abnormal sneezing, sore throat, hoarsness, 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.
Vitals
Weight:24.50 lbs. Height:31.00 inches. Temperature temporal: 97.80 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 obstructed with cerumen .
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 anterior examination of the nose, there is no evidence of purulence, polyps, masses or lesions. Polyps : Absent. On anterior exam.
Mucosa: Normal. Palate: Normal. Base of tongue: Normal. Posterior pharynx: Normal.
Inspection: Normal. Masses or lesions: Normal. Lymph nodes: Normal.
Thyroid: Normal.
ENT
Cerumen Removal Right cerumenectomy is performed under the operating microscope. A curette was used to clean the canal of material. Findings following the cerumenectomy demonstrate Right tube in place and patent with normal surrounding TM The patient tolerated this procedure well without trauma to the canal or tympanic membrane.
ICD: Chronic Serous Otitis Media (381.10)
ICD: Ceruminosis (380.4)
ICD: Eustachian Tube Dysfunction (381.81)
ICD: Chronic Mucoid Otitis Media (381.20)
ICD: Unspecified Acute Nonsuppurative Otitis Media (381.00)
Once the cerumen was removed we were able to identify the right ventilation tube. There is no evidence of extrusion at this time. We will see her back in 6 months at which time we will test her hearing.
I'll try to educate them and see what happens. Thank you!