44. A 44-year-old patient, with chronic mastoiditis, was seen in consultation by the ENT specialist in the office. Her physician was inquiring as to the advantages of surgery versus continued antibiotic treatment when an acute flare comes on. The ENT specialist recommends surgery because of the increasing severity with each acute flare. She is fearful of the surgery because of the need to go under general anesthetic and a fear of permanent hearing loss. The physician performs an expanded problem-focused history to include the duration of this problem and how many acute flares a year the patient experiences. An expanded problem-focused examination and straightforward decision making are completed. It is determined that with the number of acute flares a year and the increasing severity of each case that surgery is recommended. The patient’s fears are laid to rest, and the patient decides to go ahead with the surgery. CPT Code: ___________________ ICD-10-CM Code: _______________
