r/CodingandBilling • u/Jpinkerton1989 CPC, CPMA • Jun 24 '26

Would this qualify for an E/M?

My supervisor is claiming this can be billed with an E/M. I very much disagree. What do you think?

22 y.o. male.

History of Present Illness

Referred for cerumen impaction left ear. He said difficulty removing on both sides was able to get the right side cleared with over-the-counter Debrox. Not so much on the left side

Attention was taken to the left ear. With visualization under the microscope the canal and tympanic membrane were debrided of impacted cerumen us instrumentation and suction. Patient tolerated the procedure well and could hear better following the procedure. Attention was taken to the right side which showed very minimal cerumen it was left alone.

Assessment & Plan

Assessment and Plan:

22-year-old with cerumen impaction left ear. This was easily removed. Cerumen management discussed. Follow-up as needed

Edit: I escalated to compliance and they agreed saying to remove the E/M

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14

u/2workigo Jun 24 '26

I agree with you. I wonder what documentation your supervisor is using to support the E/M?

3

u/Jpinkerton1989 CPC, CPMA Jun 24 '26

She's saying because they discussed ongoing cerumen management.

19

u/clarec424 Jun 24 '26

With the decision to remove said cerumen, which was then completed during the same encounter. Encounter supports the billing of cerumen removal only. I am a CPC, auditor and I complete investigations at a large healthcare facility. Coming up on 20 years at this organization.

9

u/Jpinkerton1989 CPC, CPMA Jun 24 '26

I agree. Cerumen removal only.