Documentation Dissection

History of Present Illness:

The patient is an 80-year-old female who presents with a complaint of ear pain |1|.

CC: Bilateral ear pain.

HPI: Ms. Davis presents today for evaluation of left ear aching and pressure |2|. She denies sinus problems or sore throat. She has
experienced a dry cough and sneezing. She hears a “cricket sound” in the ears with mild dizziness. Symptoms have been present
intermittently for one month. She is not taking OTC medication for this.

Post Diagnosis: Impacted Cerumen (Wax in Ear) Left Ear |3|.

Allergies:
No Known Drug Allergies

Vitals 10/02/2014 11:25 AM

Weight: 126 lb; Height: 63 in

Body Surface Area: 1.59 m2; Body Mass Index: 22.32 kg/m2

Temp: 98.5°F (Oral); Pulse: 102 (Regular); P.OX: 95% (Room air)

BP: 120/78 Electronic (Sitting, Left Arm, Standard)

ENMT
Global Assessment:
Upon examination of the ears, nose, mouth and throat—on assessment of hearing, the patient has normal hearing threshold.

Ears:
External Auditory Canal—Left – external auditory canal is impacted with cerumen |4|.
Right—No cerumen impaction noted, no drainage observed and no edema noted in EAC.

Nose and Sinuses:

External Inspection of the Nose—Boggy turbinates. Inspection of the nares—Left–watery discharge noted. Right—watery
discharge noted. Nasal Mucosa—Left boggy and erythema. Right—boggy and erythema.

Mouth and Throat

Oral Cavity/Oropharynx: Oropharynx—mild pharyngeal erythema noted.

Based on assessment of the left ear, we will perform a Tympanometry. Using the otoscope, I started to exam the left ear first.
Earwax visible. No foreign objects visible. Air pressure applied. Left eardrum responded as expected. No fluid. Normal pressure
and normal movement of left eardrum. +50 daPa. Moving to the right ear. Again very little earwax visible. Air pressure applied. No
fluid. Normal pressure and normal movement of right eardrum. +50 daPa. Right eardrum responded as expected |5|.

Current Plans:
We’ll try decongestants and nasal spray and follow up in one month.
• Started Ipratropium Bromide 0.06%, 1 squirt each nostril two to four times daily for sinuses and ears, 1 cannister, 30 days,
Ref. x5.
• Started Mucinex D 60-600 MG, 1 Tablet ER 12 HR two times daily for ears and sinuses, #28, 14 days, No Refill.

1
_____________________________________________________________
|1| Presenting problem.
|2| Additional symptoms.
|3| Findings for final diagnosis.
|4| Exam findings.
|5| Procedure performed.

_____________________________________________________________

What CPT® and ICD-10-CM codes are reported?

CPT® Code: 92567

ICD-10-CM Code: H61.22

Rationales:
CPT®: Test of middle ear function using variations in air pressure; also known as impedance testing.

Look in the CPT® Index for Tympanometry. You are referred to codes 92550, 92567, 92570. In the CPT index is an additional note
under Tympanometry to see Audiologic Function Tests/Tympanometry 92550, 92567, 92570. Code 92567 describes Tympanometry
(impedence testing). This code requires testing of both ears.

ICD-10-CM: In the ICD-10-CM Alphabetic Index look for Cerumen (accumulation) (impacted) H61.2-. This can also be found
by looking for Impaction/cerumen (ear) (external). In the Tabular List a 5th character 2 is required to identify the left ear. H61.22
Impacted Cerumen, Left Ear is correct.