wynonna
True Blue
Assessment and Plan
(1) Tinnitus of both ears:
Plan:
Impression: Bilateral non bothersome tinnitus secondary to presbycusis
Plan: Hearing protection discussed
(2) Presbycusis, bilateral:
Intake
Visit Reasons: Tinnitus
HPI
Patient presents with a chief complaint of bilateral tinnitus. He has had tinnitus as long as he can remember but the past 6 months that has become significantly louder. It is not bothersome however and does not interfere with sleep. He feels he may have slight gradual progressive hearing loss. He denies otalgia, otorrhea or dizziness. Other than cerumen impactions he has no prior otologic history. He had significant noise exposure as he played drums through college. He is a police officer and always uses hearing protection at the shooting range. He uses hearing protection when operating power tools. He denies nasal congestion.
The rest of note is Exam and medical and Social history and Meds taken by patient.
There are no procedures being done nor ordered/discussed.
Which level would you code for this new patient?
thank you fellow coders.
(1) Tinnitus of both ears:
Plan:
Impression: Bilateral non bothersome tinnitus secondary to presbycusis
Plan: Hearing protection discussed
(2) Presbycusis, bilateral:
Intake
Visit Reasons: Tinnitus
HPI
Patient presents with a chief complaint of bilateral tinnitus. He has had tinnitus as long as he can remember but the past 6 months that has become significantly louder. It is not bothersome however and does not interfere with sleep. He feels he may have slight gradual progressive hearing loss. He denies otalgia, otorrhea or dizziness. Other than cerumen impactions he has no prior otologic history. He had significant noise exposure as he played drums through college. He is a police officer and always uses hearing protection at the shooting range. He uses hearing protection when operating power tools. He denies nasal congestion.
The rest of note is Exam and medical and Social history and Meds taken by patient.
There are no procedures being done nor ordered/discussed.
Which level would you code for this new patient?
thank you fellow coders.