Wiki level 2 or 3?

[wynonna]

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?

 

[Bernadette10]

I think level 2. Problem complexity low for one stable, established problem and one acute, uncomplicated problem. Limited data since the audiogram reviewed would have been counted at the previous encounter when it was ordered, and the new audiogram that was recommended would be one test counted. Minimal risk for the audiogram recommended.

 

[wynonna]

Thank you!