wynonna
True Blue
Regarding outpatient E/M, 2021 guidelines:
HPI
Patient returns in follow-up for his slightly asymmetric sensorineural hearing loss and bilateral tinnitus. He is not aware of a change in his hearing. There is no change in his bilateral tinnitus which sometimes interferes with sleep. He does try masking with television. He has had occasional slight dizziness but none in more than a year. He has extensive history of occupational noise exposure and has had numerous occupational audiograms that showed the left being worse than the right.
Assessment and Plan
(1) Asymmetrical sensorineural hearing loss:
Plan:
Impression: Relatively stable mildly asymmetric sensorineural hearing loss
Plan: Repeat audiogram 1 year, importance emphasized, unlikely risk of acoustic neuroma mentioned
(2) Tinnitus of both ears:
Plan:
Tinnitus masking is discussed
Exam is problem focused.
Bill 99212, or 99213?
HPI
Patient returns in follow-up for his slightly asymmetric sensorineural hearing loss and bilateral tinnitus. He is not aware of a change in his hearing. There is no change in his bilateral tinnitus which sometimes interferes with sleep. He does try masking with television. He has had occasional slight dizziness but none in more than a year. He has extensive history of occupational noise exposure and has had numerous occupational audiograms that showed the left being worse than the right.
Assessment and Plan
(1) Asymmetrical sensorineural hearing loss:
Plan:
Impression: Relatively stable mildly asymmetric sensorineural hearing loss
Plan: Repeat audiogram 1 year, importance emphasized, unlikely risk of acoustic neuroma mentioned
(2) Tinnitus of both ears:
Plan:
Tinnitus masking is discussed
Exam is problem focused.
Bill 99212, or 99213?