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Wiki level 2 or 3 for hearing loss?

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wynonna

True Blue
Messages
540
Location
Hinsdale, MA
Best answers
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Assessment and Plan
(1) Asymmetrical sensorineural hearing loss:
Plan:
Impression: Resolution of right low-frequency sensorineural hearing loss suggestive of cochlear Ménière's disease but he has no other symptoms and is not aware of a change

Plan: Recommend patient monitor his salt intake, repeat audiogram 1 year, call immediately for any drop in hearing
Plan Details
Follow Up:
1 year with audio with PA

Intake
Visit Reasons: f/u OE w/ audio

HPI: He is not aware of a change in his hearing since last year. He has occasional clicking tinnitus on the right. He denies aural fullness. He denies dizziness but has occasional slight disequilibrium. He is on a moderate salt diet.
 
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What's your assessment of MDM? A 99212 would be "A problem that runs a definite and prescribed course, is transient in nature, and is not likely to permanently alter health status". The patient is likely at the start of Meniere's Disease which can really change a patient's life, especially in the later stages.
 
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