Wiki Unspecified hearing loss vs V72.12/V72.19

hthomson

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HELP!

I am seeking guidance on a diagnosis code for a hearing exam. Below is an example
of the note in question. The provider wants to code 389.9 and I believe that this is a screening exam and that either V72.12 or V72.19 should be used.

History: Patient is here as part of physical for XXXX XXXX academy. Patient has no cornerns regarding their hearing. Denies: dizziness, tinnitus, ear surgery, otalgia.

Impressions: excess cerumen is noted bilaterally. Hearing is within normal limits with excellent word recognition ability in each ear. Normal middle ear function bilaterally.

Recommendations: Cerumen removal for both ears is recommended. Audiologic re-evaluations are recommended as needed. Physical form was filled out and given back to the patient today.

Any thoughts or advice would be greatly appreciated.
Thank You.
 
there is no question here. You absolutely cannot use a dx code that is not documented. There is no hearing loss documented , in fact just the opposite, this is a hearing screening only.
 
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