Wiki ear wax in exam?

wynonna

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ear wax in exam?
Hello fellow ENT coders.
(Regarding E/M coding for office visit)
When cerumen is noted in HPI and Procedure section and Assessment, does it still need to be noted in EXAM section?
 
Not sure I understand your question. Cerumen is in any normal ear. It’s not a reportable condition or disease unless it’s impacted or otherwise causing a problem for the patient. And there’s no requirement I know of that something noted in an HPI must also be in the exam. Where is that coming from?
 
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This is a confusing question but I think you are asking if it would be reasonable to see cerumen commented on in the exam area of a note if there was reference to it in the HPI and the provider removed ear wax as documented in a procedure note?
For example, the chief complaint was excess ear wax or something and the procedure documentation indicated removal of impacted cerumen with instrumentation. I would expect to see it commented on in the ear exam of the E/M note but it depends.

If that is the question, I think it depends on the specific note/situation for each patient encounter.
 
Not sure I understand your question. Cerumen is in any normal ear. It’s not a reportable condition or disease unless it’s impacted or otherwise causing a problem for the patient. And there’s no requirement I know of that something noted in an HPI must also be in the exam. Where is that coming from?
Thomas, I agree.
We would probably need to see the note with redated PHI to provide you a better answer.
 
Yes, so in order to bill 69210 for cerumen impaction removal, we need to see cerumen impaction noted in EXAM section, not just procedure section and chief complaint.
Just wanted verification from other coders.
 
Yes, so in order to bill 69210 for cerumen impaction removal, we need to see cerumen impaction noted in EXAM section, not just procedure section and chief complaint.
Just wanted verification from other coders.

Yes, that is correct, but keep in mind that in order to bill an E/M with 69210, there needs to be work outside of the pre and post work involved in the procedure. Otherwise, only the 69210 would be billable.
 
Yes, so in order to bill 69210 for cerumen impaction removal, we need to see cerumen impaction noted in EXAM section, not just procedure section and chief complaint.
Just wanted verification from other coders.
No, I disagree. There's no coding rule that says you don't code something if the provider documented it in one place but not in another in the record. Actually, in my opinion, it would be incorrect coding to omit or fail to code a documented diagnosis and procedure for this reason. If anyone tells you there is such a rule, then they need to show it to you and give you the source. Honestly, I'm not sure why anyone would tell you to do such a thing - make a procedure that provider performed and documented 'not billable', thereby deciding that the provider should not be paid for their work - because they wrote the diagnosis in two places in the record but didn't write that same thing a third time under the exam.

If the documentation is truly deficient and can't be coded, then the correct remedy is to query the provider for a clarifying amendment, not to make their work 'non-billable'. Personally, I wouldn't trouble the provider with something as trivial as this because providers have a lot more important things to do than changing medical records around because of rules that coders come up with that don't really exist. Perhaps just jot it down as a recommendation or an FYI to give them the next time you have a documentation improvement session with them. Coding efforts should be focused on larger issues that impact revenue or put the practice at risk, not on minor technicalities or imperfections in individual notes.
 
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I agree with Thomas, that the cerumen impaction needs to be documented in the exam, BUT it must be documented that the cerumen is "impacted" in order to bill for the removal of the cerumen.
 
No, I disagree. There's no coding rule that says you don't code something if the provider documented it in one place but not in another in the record. Actually, in my opinion, it would be incorrect coding to omit or fail to code a documented diagnosis and procedure for this reason. If anyone tells you there is such a rule, then they need to show it to you and give you the source. Honestly, I'm not sure why anyone would tell you to do such a thing - make a procedure that provider performed and documented 'not billable', thereby deciding that the provider should not be paid for their work - because they wrote the diagnosis in two places in the record but didn't write that same thing a third time under the exam.

If the documentation is truly deficient and can't be coded, then the correct remedy is to query the provider for a clarifying amendment, not to make their work 'non-billable'. Personally, I wouldn't trouble the provider with something as trivial as this because providers have a lot more important things to do than changing medical records around because of rules that coders come up with that don't really exist. Perhaps just jot it down as a recommendation or an FYI to give them the next time you have a documentation improvement session with them. Coding efforts should be focused on larger issues that impact revenue or put the practice at risk, not on minor technicalities or imperfections in individual notes.

I do not agree that it needs to be documented in the HPI for sure.
However, for the exam portion, how would one justify the discovery of the impacted cerumen if it's not documented in the exam? If a patient is referred for impacted cerumen, than the provider should still need to verify/examine that area before moving forward with the procedure. I do not think that it was implied that coders are creating rules that don't exist.
 
I do not agree that it needs to be documented in the HPI for sure.
However, for the exam portion, how would one justify the discovery of the impacted cerumen if it's not documented in the exam? If a patient is referred for impacted cerumen, than the provider should still need to verify/examine that area before moving forward with the procedure. I do not think that it was implied that coders are creating rules that don't exist.
I hear what you're saying and would agree that omitting a finding in the exam could indicate poor quality documentation on the part of the provider. However, the ICD-10 guidelines is quite clear about this in section 1.A.19: "The assignment of a diagnosis code is based on the provider’s diagnostic statement that the condition exists. The provider’s statement that the patient has a particular condition is sufficient. Code assignment is not based on clinical criteria used by the provider to establish the diagnosis. If there is conflicting medical record documentation, query the provider."

If impacted cerumen was documented in the procedure section of the record, then that is sufficient, and you can and should assign the code. Exam findings fall into the category of 'clinical criteria'. Coders don't need to determine whether or not exam findings support a diagnosis - that's the provider's job and not the coder's. However, as stated in the guideline, if there is conflicting information (e.g if the exam stated 'no impacted cerumen' and the diagnosis stated 'impacted cerumen', then a query would be required rather than not billing. But I wouldn't query to tell the provider that need to copy the diagnosis over into the exam if it wasn't there - that would just be a waste of their time if the diagnosis has already been documented by the provider in the record.
 
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