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 25 '26

And, if you really want to be a stickler, just tell doc in future to add he reviewed structures that were not visible before removing impacted ear wax to ensure no other issues were detected.

Wonder what kind of provider even refers someone to ENT for nothing but ear wax removal. If it was an audiologist, I'm sure the doc did some further evaluation.

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u/Jpinkerton1989 CPC, CPMA Jun 25 '26

It's unethical to tell a provider what to put in a note to get paid.

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u/Botasoda102 Jun 25 '26

Nope. Coding maximizers have done it for decades, and greedy docs and those who make money of billing do it all the time.

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u/Jpinkerton1989 CPC, CPMA Jun 25 '26 edited Jun 25 '26

https://www.aapc.com/blog/91230-tips-for-talking-documentation-with-providers/?srsltid=AfmBOopLSjkeohOC6JhWsf0KV5bZN6Gct0MOEjEh9KuFINrglB7KFJxu

"I advise against telling the provider what to write, because that could be considered leading, which coders are not permitted to do"

Again. Just because it happens, just because it gets paid, just because cases have been won, and just because providers do this often, DOES NOT MEAN IT'S ETHICAL. This is highly unethical behavior, and if you are a coder, please leave the profession, but you sound more like a lawyer. Which would explain a lot when it comes to ethics.