wynonna
True Blue
Hello E&M coders:
(1) Sensorineural hearing loss (SNHL) of both ears:
Plan:
Impression: Stable sensorineural hearing loss
Plan: Recommend repeat audiogram in 2 years, call if any drop in hearing
(2) Dysfunction of both eustachian tubes:
Plan:
Not clinically significant at this time
HPI
Patient returns in follow-up for her sensorineural hearing loss. She first noticed it in her 30s. She had undergone myringotomy and tubes with adenoidectomy. She is not aware of any recent change. She denies otalgia, otorrhea, tinnitus, or dizziness. There is no family history of hearing loss. She denies significant noise exposure.
(1 element in exam and 1 audiogram billed by audiologist reviewed)
Which level would you choose?
(1) Sensorineural hearing loss (SNHL) of both ears:
Plan:
Impression: Stable sensorineural hearing loss
Plan: Recommend repeat audiogram in 2 years, call if any drop in hearing
(2) Dysfunction of both eustachian tubes:
Plan:
Not clinically significant at this time
HPI
Patient returns in follow-up for her sensorineural hearing loss. She first noticed it in her 30s. She had undergone myringotomy and tubes with adenoidectomy. She is not aware of any recent change. She denies otalgia, otorrhea, tinnitus, or dizziness. There is no family history of hearing loss. She denies significant noise exposure.
(1 element in exam and 1 audiogram billed by audiologist reviewed)
Which level would you choose?