Assume these patients are covered under Medicare A & B. Use the following physician notes to indicate diagnosis and procedure codes that would be used in billing for these patients. The bill is for the physician services or physician office services only. Assume the office has a CLIA waived testing lab on site
Patient: Drew Carrigan, 68-year-old male
Physician Note:
S: Drew is an established patient presenting with "ringing in the ears." Drew states that it started quite a while ago, but it is now interfering with his ability to hear normal conversations. Drew cannot identify any triggers or treatments that have helped; he reports it is a constant ringing and has had no trauma or sinus issues.
O: Ht: 58 inches, Wt 200 lbs; BP 120/80; Respirations 12; Temp 97.6F; Pulse ox 100% on room air; Pulse 63. Ears have no signs of infection or injury. Hearing screening test, pure tone, air only shows hearing is within normal limits.
A: R/O Tinnitus, consider CT scan/MRI after audiology consult.
P: Referral to audiology.
Diagnosis codes:
Procedure codes:
What will be an ideal response?
Diagnosis Codes: 388.30 (Tinnitus, unspecified)
Procedure Codes: 99214 (Evaluation and Management), 92551 (Hearing screening test, pure tone, air)
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