Follow-up Cerumen Impact E/M Visit

May 12, 2016

A new patient only came in for an ear cleaning and I only billed for an ear cleaning (even though I do open a new chart for this patient) because there wasn’t really another diagnosis to support an E/M code. When the same patient comes back for a visit for sinusitis, do I now get to bill a new patient code (9920x)?

Actually, at this point you will report an established patient visit code for the sinusitis visit because you’ve had a previous face-to-face visit with the patient. So now the patient is an established patient (9921x) to you. If the patient had received only an audiogram service, without a face-to-face service from you, then the patient would be new (9920x) to you for the follow-up sinusitis visit.

*This response is based on the best information available as of 05/12/16.

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