Helping in Auditing a provider who uses 92504 pretty often and I was hoping if someone had some information in correct documentation for procedure 92504? he is only documenting that ears were examine under microscope, is that correct? or sufficient to bill 92504?

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Chief Complaint
Patient presents with
• Hearing Loss

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Notes gradual progressive hearing loss worse on right.
Mild pressure AU.
No dizziness.
No tinnitus.
No drainage.
No ear surgery.
No hearing aids.
+loud noise exposure.
No family history of hearing loss.
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Review of Systems
Constitutional: Negative for chills, fever, malaise/fatigue and weight loss.
HENT: Positive for hearing loss. Negative for congestion, ear discharge, ear pain, nosebleeds, sore throat and tinnitus.
Eyes: Negative for blurred vision and double vision.
Respiratory: Negative for cough and sputum production.
Cardiovascular: Negative for chest pain and palpitations.
Gastrointestinal: Negative for heartburn and nausea.
Musculoskeletal: Negative for myalgias and neck pain.
Skin: Negative for itching and rash.
Neurological: Negative for dizziness and tingling.
Endo/Heme/Allergies: Negative for environmental allergies. Does not bruise/bleed easily.

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Objective:
Physical Exam
Constitutional: He is oriented to person, place, and time. Vital signs are normal. He appears well-developed and well-nourished.
HENT:
Head: Normocephalic. Head is without raccoon’s eyes and without Battle’s sign.
Right Ear: Ear canal normal. No drainage, swelling or tenderness. No mastoid tenderness. Tympanic membrane is retracted. Tympanic membrane is not scarred, not perforated, not erythematous and not bulging. No middle ear effusion. No hemotympanum.
Left Ear: Ear canal normal. No drainage, swelling or tenderness. No mastoid tenderness. Tympanic membrane is retracted. Tympanic membrane is not scarred, not perforated, not erythematous and not bulging. No middle ear effusion. No hemotympanum.
Nose: Nose normal. No mucosal edema, nasal deformity or nasal septal hematoma. No epistaxis.
Mouth/Throat: Uvula is midline and mucous membranes are normal. No oral lesions. No uvula swelling or lacerations. No oropharyngeal exudate, posterior oropharyngeal edema or posterior oropharyngeal erythema.
Retraction with TM adherence to the stapes AD.
Retraction with TM touching the stapes AS.

Eyes: EOM are normal. Pupils are equal, round, and reactive to light.
Neck: Trachea normal and phonation normal. Neck supple. No spinous process tenderness and no muscular tenderness present. No neck rigidity. No tracheal deviation, no edema and normal range of motion present. No thyroid mass and no thyromegaly present.
Cardiovascular: Normal rate and regular rhythm.
Pulmonary/Chest: Effort normal and breath sounds normal. No accessory muscle usage or stridor. No respiratory distress. He has no decreased breath sounds.
Abdominal: Soft.
Lymphadenopathy:
Head (right side): No submental, no submandibular, no preauricular and no posterior auricular adenopathy present.
Head (left side): No submental, no submandibular, no preauricular and no posterior auricular adenopathy present.
He has no cervical adenopathy.
Right cervical: No superficial cervical, no deep cervical and no posterior cervical adenopathy present.
Left cervical: No superficial cervical, no deep cervical and no posterior cervical adenopathy present.
Neurological: He is alert and oriented to person, place, and time. No cranial nerve deficit or sensory deficit.
Skin: Skin is warm and dry. No rash noted. No erythema.
Nursing note and vitals reviewed.
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Both ears exam under microscope today.
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Assessment:
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1. Tympanic membrane retraction, bilateral *
2. Asymmetrical hearing loss, right *
3. ETD (Eustachian tube dysfunction), bilateral *
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Plan:
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Self politzerization twice a day or if unable then place tubes.
Cleared for hearing aids.
Avoid loud noise exposure.
F/u 6 months.