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Indications / Associated Pathologies: Congenital Anomaly Neck Trauma Respiratory Failure Subcutaneous Emphysema Upper Airway Edema, Foreign Body, or Obstruction Description: Tracheostomy involves creating a stoma (surgical opening) in the neck to bypass the cervical trachea and/or oropharynx, allowing air to pass directly to the distal trachea for respiration. It may be performed on patients requiring … Read more
Key Terms: Decompressive Foraminectomy Foraminal Decompression Indications / Associated Pathologies: Degenerative Joint Disease Spinal Radiculopathy Spinal Myelopathy Spinal Stenosis Synovial Cyst Description: Spinal stenosis may result from degenerative osteoarthritis, osteophyte or bone spur formation, or ligamentum flavum hypertrophy. Decompressive laminectomy involves removing the lamina and enlarging the spinal canal to relieve pressure on the spinal … Read more
Diagnosis and Medical Necessity The diagnosis establishes the medical necessity for the service provided. Major Differences Between ICD-10-CM and CPT Codes is that ICD-10-CM codes and CPT® codes serve different purposes. While CPT codes describe the procedure or service provided, ICD-10-CM codes explain the reason for the service. Accurate selection of diagnosis codes is crucial … Read more
Introduction: The major revisions to the coding guidelines for office/other outpatient evaluation and management (E/M) visits (CPT codes 99202-99205 and 99211-99215) were implemented nearly four years ago. While these updates aimed to streamline the coding process, practices continue to encounter challenges in documentation and reporting. Such confusion can lead to improper coding and potential financial … Read more
Basics of Baclofen Pump Insertion Key Terms: Intrathecal Pump Insertion Trial Intrathecal Catheter Insertion Indications / Associated Pathologies: Baclofen pumps are used to treat muscle spasticity caused by conditions such as: Cerebral Palsy Multiple Sclerosis Spinal Cord Injury Stroke Traumatic Brain Injury Description: The intrathecal Baclofen pump system is designed to treat moderate to severe … Read more
Deep Brain Stimulator (DBS) and Intracranial Responsive Neurostimulator (RNS) Lead Insertion Key Terms: DBS Lead(s) RNS Lead(s) Indications and Associated Pathology: Deep Brain Stimulation (DBS) and Responsive Neurostimulation (RNS) are used to treat various neurological and psychiatric conditions, including: Localization-related (focal) (partial) idiopathic or symptomatic epilepsy Essential tremor Intractable dystonias Meige syndrome Multiple sclerosis Obsessive-compulsive … Read more
When deciding whether to perform an Annual Wellness Visit (AWV) in conjunction with an Evaluation and Management (E/M) office visit or as two separate appointments, healthcare providers need to weigh several factors. Each approach has distinct advantages and challenges for both the patient and the provider. 1. Pros of Combining the AWV and E/M Visits … Read more
When coding office or outpatient visits based on time, it is essential to consider the total minutes a physician or qualified healthcare professional spends on various activities, including time spent updating the patient’s medical record. These activities must take place on the same calendar date as the face-to-face encounter. Key Points about Time-Based Coding: Time-based … Read more
Basics of 2025 Telemedicine Codes The 2025 CPT manual introduces 16 new telemedicine codes designed for real-time encounters, which are divided into those conducted via synchronous audio-video connection and audio-only connection. These codes mirror the structure of office and outpatient evaluation and management (E/M) codes. It is essential to note that the services must be … Read more
Researchers have dedicated decades to advancing treatments for individuals diagnosed with malignant neoplasms, commonly referred to as cancer. Their efforts have yielded significant progress, as evidenced by the increasing number of patients diagnosed with this formidable disease who are living longer, healthier lives. In 2025, further proof of these advancements will be seen with the … Read more