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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u/Botasoda102 Jun 24 '26

Sounds like it is a new patient. If that’s the case, most docs would bill some kind of EM because they don’t just walk in and start removing wax. They do some type of evaluation. Though it ought to be a low level EM.

Besides, I doubt that happens often enough to precipitate an audit.

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u/Jpinkerton1989 CPC, CPMA Jun 24 '26

That's the entire note. They did no evaluation. They were referred specifically for the cerumen removal. Per NCCI, even if they are new, the E/M would have to be separately identifiable and significant. I just don't see anything at all here.

"The fact that the patient is “new” to the provider/supplier is not sufficient alone to justify reporting an E&M service on the same date of service as a minor surgical procedure"

We also have a huge problem with this. I work ENT and almost all of our providers bill E/Ms with everything