Cerumen Removal - The ENT portion under the exam

ieshiarenee

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Can I have some input on this please?

The ENT portion under the exam states Otoscoptic examination: Abnormal. Normal after cerumen removal.

He then dictates a procedure note detailing the cerumen removal. Can he get credit for this? I feel the exam needs to specify R/L/B cerumen impaction.

Thank you!
 

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CodingKing

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There needs to be documentation of impaction so cannot bill separately for the removal. Its bundled in the E&M.
 
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