Celebrating 10 years with NurseValue, Inc.

NurseValue, Inc. celebrates our 10 year anniversary on February 1, 2016. What a wonderful run we’ve had!  A special thanks to those who have trusted us with their most difficult cases.  We look forward to providing the same outstanding service to our accounts for many more years to come. 

What did they do to me in Physical Therapy?

Did they actually perform the therapy that that was billed?  A lot of names for physical therapy are tossed around.  Many have more than one definition within the main category.  To add to the confusion there are often just letters that represent the service.  I have assembled a few of the most common ones that are found in occupational therapy, physical therapy and chiropractic therapy notes. 

 Manual Therapy: 

• Hands on movement of joints and surrounding tissues by therapist to enhance the healing process by decreasing pain and increasing motion
• Joint Mobilization (JM):  Techniques to increase joint range of motion.  Restores normal joint movement and circulation to the joint.
• Myofascial release (MFR):  A “hands-on” treatment used to simultaneously assess and relax restricted soft tissues.
• Soft-Tissue Massage (STM):  Directed at trigger points, scars and muscle adhesions.  To improve blood flow, mobility and length of tissue.

 Exercise: 

• Passive Range of Motion (PROM):  A “hands-on” technique by a therapist to help increase a joint’s range of motion.
• Flexibility Exercises:  Exercise used to decease muscle tightness, improve soft-tissue and muscle length and increase range of motion
• Strengthening Exercises:  Use of resistance to increase muscle strength, tone and bulk.  Free weights or weight machines may be used.
• Manual Resistive Exercises:  Therapist applies resistance against patient’s effort through the range of motion to increase strength.
• Isokinetic Exercises:  A form of strengthening exercises using variable resistance at a fixed speed of movement.  Can also be used as a testing procedure.  Various brands of equipment include Cybex, Kin-Com, Biodex and Lido.
• Home Exercise Program (HEP):  Instruction in specific individualized exercise or functional activities to enhance improvements made in therapy.  Revised on an on-going basis as the patient progresses.
• Therapeutic Activities:  Activities or exercises designed to improve functional performance through simulation of functional movements, i.e. stair climbing.
• Neuromuscular Re-Education:  Exercises to improve balance, coordination, stabilization, posture and proprioception to correct movement patterns.
• Gait Training:  Instruction in use of devices such as crutches or cane, or correction of gait pattern.  Selection and fitting of assistive device may be included.

 Modalities: 

• Physical agents used to reduce swelling, pain and to prepare tissues for therapeutic exercises
• Biofeedback (EMG, BFB):  A device used to identify muscular activity and assess muscle imbalances.  Treatment may be designed to enhance or relax specific muscle groups. Often used for pain control.
• Cold Pack and Ice Massage (CP):  Also referred to as “Cryotherapy”.  Used to decrease pain, spasm, and swelling.
• Hot Packs or Moist Heat (HP or MH):  Packs of moist heat used to promote healing and relaxation and decrease pain.
• Electric Stimulation:  Electrical Muscle Stimulation (EMS):  An electrical device, which uses different frequencies of electronic current to treat a variety of conditions.  Indicated for swelling, pain, muscle spasms, nerve injury and re-educating weak muscles.
• Transcutaneous Electrical Nerve Stimulation (TENS):  Nerve stimulation device that helps to relieve acute or chronic pain. 
• Microcurrent Electrical Nerve Simulation (MENS):  Technique which uses very low levels of current to stimulate cellular growth and repair at the injury site.
• Interferential (IFC):  Another form of electrical stimulation used to decrease pain or swelling.
• Ultrasound (US):  Deep penetrating heat generated by sound waves.  Used to decrease swelling and muscle spasm.  Usually feel a minimal warmth since ultrasound reaches up to two inches below the skins surface.
• Phonophoresis:  Medicine, in a paste or gel, transferred by low levels of electrical current into tissue surrounding an injury site.
• Traction:  Often used for disorders of the neck and back.  A mechanical pull of soft tissue and joints to decrease pressure, relieve pain and guard muscles. 

 

Orthopedic Diagnostic Testing

When reviewing medical records, I like to have a handy sheet remind me of the reason for the orthopedic tests that that are not intuitive as they often are named after a person.  Below are some of the common ones that I see in records for musculoskeletal examinations: 

 

Neck:

Adson Test	The arm being tested is held in a dependent position while the head is rotated from side to side. The test is positive for thoracic outlet syndrome if there is an obliteration of the radial pulse.
Allen's Test	While the patient raises one arm and makes a fist the examiner compresses the radial and ulnar arteries. Once the arm is lowered and the hand opened, the examiner releases one of the arteries then repeated releasing the other artery. If there is no flushing of the hand upon release of one of the arteries, the test is positive indicating a vascular occlusion of the released artery.
Compression Test	The examiner places their hands on the top of the patient's head and presses down causing a narrowing of the neural foramen. The test is positive if increased pain is noted and indicates nerve root irritation.
Spurling Test	Patient is asked to look up, turn the neck to one side while gentle downward pressure is applied to the head. The test is positive indicating a pinched cervical nerve when the patient reports pain and tingling.

 

Back:

Bragard Sign	The lower extremity is flexed at the hip with the knee stiff until the patient experiences pain then the foot is dorsiflexed. Increased pain is a positive sign indicating nerve involvement.
Heel and Toe Walk Test	The patient walks on their heels indicating L4-L5 nerve root irritation if they are unable to perform this activity. If unable to walk on their toes this indicates lumbar nerve root irritation.
Lasegue Sign	The patient is able to flex the hip with the knee bent without experiencing pain. The examiner then raises the straightened leg by the heel. The test is positive if there is pain indicating nerve root irritation.
Patrick Test	A test to distinguish sciatica from lumbosacral or hip pain. With the patient lying supine, the examiner places the ankle of the affected side over the patella of the opposite leg and pressure is placed on the flexed knee. Patients with sciatica will not experience pain while those with lumbosacral or hip disorders will.
Straight Leg Raising Test	Patient lifts leg with the knee remaining straight, a positive test will result in pain along the sciatic nerve suggesting nerve root irritation.
Waddell Test	Five or more tests for malingering in patients complaining of back pain. The tests include tenderness, simulation (axial loading and rotation), straight leg raising, regional disturbances (weakness or sensory disturbances) and overreaction. The Waddell test is positive if the patient has positive results and complains of pain in three or more of the five tests, suggesting the complaints are non-organic.

 

Shoulders:

Apprehension Test	The patient's arm is extended, held abducted and externally rotated. The patient will be apprehensive in a positive exam, motion will be painful to patients with anterior subluxing or dislocating shoulder.
Drop Arm Test	The arm is lifted to a fully abducted position then lowers the arm slowly towards their side. The test is indicative of a rotor cuff tear if the patient cannot actively control lowering the arm past 90 degrees.
Impingement Test	The examiner forcefully abducts and internally rotates the shoulder causing the greater tuberosity of the humerus to impinge the undersurface of the acromion. A positive test could indicate an impingement syndrome or rotator cuff tendonitis.

 Hands:

Finkelstein Sign	The thumb is folded into the palm of the hand and fingers are closed around it while the wrist is gently pushed down. The test is positive when there is pain in the thumb side of the wrist. Pain indicates synovitis of the abductor pollicis longus tendon to the wrist also known as DeQuervain's Tenosynovitis.
Phalen's Test	The wrist is flexed as far as it will go and held for one minute which compresses the median nerve that runs through the carpal tunnel at the wrist. The test is positive for carpal tunnel syndrome if the patient experiences paresthesia or pain.
Tinel's Sign	The test suggests positive findings for carpal tunnel syndrome when the patient reports tingling sensation when the examiner taps the area over the median nerve.

 Hips:

Ely Test	With the patient lying prone, the examiner flexes the leg on the thigh, bringing the heel towards the buttocks. The test is positive if the pelvis is arched away from the table, indicating tightness of the rectus femoris, contracture of the lateral fascia of the thigh, or femoral nerve irritation.
Thomas Sign	With the patient supine and flexing the opposite hip, the affected hip will rise from the table. If this occurs, the test is positive indicating hip joint flexion contracture.
Trendelenburg Test	The examiner stands behind the patient while they lift one leg then the other. If the pelvis drops downward on the non-weight bearing side the test is positive suggesting muscle weakness of the weight-bearing hip.

 

 

Knees:

 

Apley Test	While prone the patient compresses their knee at 90 degrees, the examiner rotates the tibia in both directions. The test is repeated with the knee joint under distraction (pulling the patient's foot upward). If the patient experiences pain on compression, the test indicates a meniscal injury; pain upon distraction suggests a ligamentous injury.
Drawer Sign	With the patient supine and knee flexed 90 degrees, the proximal tibia is pulled anteriorly and then pushed posteriorly. Excessive movement while being pulled suggests a torn anterior cruciate ligament. Excessive movement while being pushed suggests a torn posterior cruciate ligament.
Lachman Test	This test is performed with the patient supine and the knee flexed to 20 degrees. The examiner pulls the tibia anteriorly. A torn anterior cruciate ligament is indicated by a "give" reaction.
McMurray's Test	The patient is supine. The examiner rotates the foot outward and slowly extends the knee from a fully flexed position. The test is repeated but with the foot rotated inward. The test is positive if a "clicking" is noted while extending the knee. A "click" with the foot rotated outward indicates a tear of the medial meniscus, while a "click" with the foot rotated inward indicates a lateral meniscus tear.
Pivot Shift Test	This test is for a torn anterior cruciate ligament. The examiner internally rotates the leg with the knee fully extended. With valgus stress, the knee is gradually flexed. The test is positive if the knee shifts at 30 to 40 degrees.
Slocum Test	This test is for rotatory instability of the knee. The patient is supine with the knee flexed 90 degrees, and the foot internally rotated. The examiner sits on the patient's foot and pulls the proximal tibia anteriorly. This test is repeated with the foot externally rotated. Excessive motion of the joint indicates a rotatory instability of the knee.

The Appropriate Modifier for an Assistant in Surgery

In the event that an operative report indicates an assistant at surgery and the physician documents the purpose of the assistant appropriately, the next consideration is determining what modifier is appropriate for the surgical codes.  There are a number of options to choose from and each has its documentation requirements.

The modifier 80 identifies a surgical assistant.  Assisting surgeons usually charge between 20 to 25 percent of their normal fee for performing the surgery alone.  This reviewer has noted that often the charge is the full surgery fee normally charged by the surgeon.  This occurs most often due to the coding software that produces a fee for the main code and does not take into consideration the modifier.

Modifier 81 is appended when there is a minimum assistant at surgery.  This modifier is used when the surgeon plans to perform the procedure on his own, but due to circumstances in the surgical suite requires the assistance of another surgeon for a short period of time

Modifier 82 indicates that the procedure was performed requiring the presence of an assistant surgeon when a qualified resident surgeon was not available. In teaching hospitals, special requirements must be met to allow billing for an assistant surgeon, and modifier 82 is typically used in those instances. Check with your Medicare carrier for details.

Modifier AS is added to the primary surgical code when the assistant at surgery is a physician assistant, nurse practitioner, or clinical nurse specialist.  This modifier again requires specific documentation.  The operative report should note that no qualified resident was available, the reason for the assistant’s services, and a statement indicating that the primary surgeon has a policy of never involving residents in the preoperative, operative, or postoperative care of his/her patients.

As with medical coding in general, all surgical modifiers must provide documentation as to the reason for the modifier and appending the code to an appropriate root surgical code.

Assistant at Surgery Billing

The first consideration in billing for an assistant surgeon is to be knowledgeable of the surgeries that require assistant surgeons.  The source that I use for this important consideration is the American College of Surgeon’s “Assistant Surgeon Study”.  It should be noted that this is a guideline and ultimately the surgeon and assistant surgeon’s documentation in the operative report will determine if an assistant surgeon will be allowed.  

To bill for an assistant at surgery, the surgeon is required to specify in the body of the operative report what the assistant actually does. It is not sufficient evidence of participation to list the assistant’s name in the heading of the operative report. It is also a good idea to mention in the indications paragraph why there is a need for an assistant.

Once an operative report has been signed by the surgeon, it becomes a legal document and cannot be altered or redone. For claims denied for lack of documentation for assistant at surgery claims, the surgeon can dictate an addendum to the operative report and the claim can be resubmitted.

ICD 10 Compentency!

Barb King and Cortney Hubbard have successfully passed the course and testing to ensure ICD 10 proficiency! Just another milestone to keep up with the medical coding changes!

 

2016 Illinois Workers Compensatioon Fee Schedule

The 2016 Illinois Workers Compensation Fee schedule is available at https://iwcc.ingenix.com/download.asp

Happy New Year!

                                                     May 2016 bring all the good things you hope for!

NurseValue’s blog has exceeded 3000 visits.  Whoop!  Whoop!  Thank you to our faithful followers.  We would like to meet your needs for good healthcare information for both our healthcare managers and healthcare consumers.  Please, feel free to let us know what you would like to see from us in the coming days.  Again, thank you!

How to Choose a Surgeon

When you have the opportunity to consider a surgical procedure, there are number of things to consider. First and foremost the best way to have the best surgical outcome is to avoid surgery entirely.  This option is not always possible, but it is important to explore all options before determining if surgery is the best option for your particular problem.  Obtaining a second opinion is something you may want to consider if you have the time.  Once that is determined that your surgery is necessary, the following suggestions may prove helpful in determining who you would like to be your surgeon.  Not all surgeons with wonderful personalities have the most skill in a particular surgery.  There is much more to consider!

·         Is the surgeon board certified and is his certification up to date?  This can be researched on http://www.abms.org

·         How often has your surgeon performed your type of surgery in the past year?  The purpose of this question is not to get the busiest surgeon in your area, but rather to choose a physician with experience in your type of surgery and not one who has never performed or rarely performed your particular surgery.

·         Not all surgeons will answer this question, but many of the good ones will—What is your success, failure or complication rates with this type of surgery?

·         Where does your surgeon plan on performing the surgery?   There are now a number of websites that provide infection rates for particular hospitals. You may access this information at

http://www.consumerreportshealth.org.  On the landing page put in Hospital and you will be taken to a page that will allow you to research hospital infection rates.  This web site provides a lot of different type of health ratings/evaluations that may prove helpful.

·         Is the surgeon and the hospital he is affiliated covered by your health plan? 

·         Does the hospital that you and your surgeon are considering follow best healthcare practices?  Luckily there are a number of hospital comparisons done by Medicare.  You can access this information at www.hospitalcompare.hhs.gov.   Put in the area code of the hospital you are considering and you will be provided with the hospitals within that zip code so you can compare the findings at each hospital. 

Prepare for the inevitable Health Emergency-Part III

We have identified several websites that will provide you additional information regarding future healthcare directives when you are unable to make decisions for yourself. 

             ·         https://www.nia.nih.gov/health/publication/advance-care-planning

 ·         http://www.americanbar.org/groups/real_property_trust_estate/resources/estate_

        planning/living_wills_health_care_proxies_advance_health_care_directives.html

·         http://mayoclinichealthsystem.org/locations/mankato/for-patients/advance-care-planning/create-your-advance-directive

     ·         https://www.justia.com/estate-planning/wills/living-wills-advanced-health-care-directives/

Prepare for the inevitable Health Emergency-Part II

 

When a major health issue arises there is often no time to prepare. It leaves us vulnerable to the decisions of others.  We can prepare for these times by discussing our wishes with at least two of our loved ones.  The reason I recommend two individuals be made aware of your wishes is that there is a possibility that you will be with one of these individuals who may also require emergency services and not be able to give directives for you. 

 

 

Below are some of the activities which will help to ensure your wishes are followed:

·         Think about your healthcare wishes carefully to determine exactly what you do and don’t want done if you are in a serious health situation

·         Choose your two representatives carefully and involve them in your plans; the person(s) you choose will be responsible for making decisions about your healthcare.  It is advisable that you choose one primary person and name a secondary person if the primary person is not available.

·         Discuss your wishes with your loved ones and your representatives

·         Obtain a “Healthcare Power of Attorney” form.  This form is often specific to the state in which you live in.  If you google healthcare power of attorney form for your state you will find a number of sites with this form.  Additionally, this form is often available at your Doctor’s office or your local hospital.  You just have to ask.  I suggest that you get 2 forms so you have one to plan on and the second to act as your final copy.

·         Fill out this form and remember that although each section has specific instructions, you may cross out a section you don’t agree with and write your precise desires.

·         Once the form is completed it is recommended that you sign it and date the form in front of a public notary.  Many banks have a notary and the services are often free or require a nominal fee.

·         Once the form is completed and notarized, keep a copy in a safe place in your home and/or in your bank box. Provide a copy to your attorney and a copy to your primary provider.  Also provide a copy of this form to both of your chosen representatives. 

·         Advise your representatives to keep this form in a safe place as they may need to provide it to the hospital or facility that you are admitted to.  This form is then kept in your medical file for the duration of your hospital or facility (i.e.:  nursing home or rehabilitation facility) stay.

It is important to note the difference between the Healthcare Power of Attorney and a Living Will.  The Living Will is limited to your deathbed concerns only.  It is used to declare your desire to or not to have life prolonging measures when there is no hope of recovery.  The Durable Power of Attorney for Healthcare covers all health care decisions and is active only when you are incapable of making decisions for yourself.  You can, however direct your healthcare power of attorney designee(s) how you would like them to act in regards to your deathbed issues within the scope of your Healthcare Power of Attorney. You may want both forms as the Living Will generally covers the do not resuscitate directives but does not deal with important medical concerns you may have leading up to this point in time.  Some facilities and hospitals may accept the forms you have written, but may also require their own specific forms during an inpatient stay. 

This is the second article concerning Healthcare delegation.  The first one was very general identifying the actions you may want to consider.  The next post will lay out some links on the internet that may provide you with additional resources and ideas regarding you plans for your future healthcare management.

Coding for Imaging Services

In most cases imaging services are split into technical and professional components.  A modifier for the technical component is added to the 5 digit CPT code (copyright per AMA).  The abbreviation for the technical component is TC and the abbreviation for the professional component is PC. 

The PC of an imaging service is for the physician’s work interpreting a diagnostic test or performing a procedure.  The modifier for PC is 26.  Depending upon the provider pricing guidelines the PC or the 26 may be added to the 5 digit CPT code to communicate that the pricing is for the physician’s portion of the imaging. (I.e. 71010-26 or 71010-TC)

The TC of an imaging service is for the non-physician work.  This portion of the imaging includes the administrative, personnel, equipment and equipment cost related to the testing.  Depending upon the provider guidelines the TC or 27 is added to the 5 digit CPT code.

Generally speaking the charge for the technical component is higher than the charge for the professional component.  However, the cost of the professional plus the cost for the technical component is not larger than the charge for the global service.  The global code is the 5 digit CPT code without modifiers.  Without modifiers appended to the CPT code it describes an imaging service in which the same billing entity provided both the professional and technical component of the service.  An example of this would be a chest x-ray that was done in the MD office and the MD in that office read the x-ray. 

Now, if this is not enough to think about, it should be noted that not all imaging services can be distinctly split into a professional and technical component.  Examples of these types of services would be the interventional radiology services (CPT codes 77401-77416).  These codes are billed as global services.

When reviewing the charges for imaging services it is important to determine if the charges are for the TC, the PC or are global. This ensures the appropriate assessment of the billing for the imaging service(s) provided.  This is not always a straight forward process.  Often there are two separate providers with two separate bills that are issued without the modifier to identify the partial service provided.  The appropriate billing price must be assessed relying on the place of service and the type of provider entity.

Prepare for the inevitable Health Emergency-Part I

The first thing that most of us think about when estate planning is a will.  There are other decisions and forms to think about.  In the upcoming posts we will discuss the living will and the Healthcare Power of Attorney. These two forms provide you with a voice for your healthcare should you not be able to speak for yourself.

Celebration of Veterans everywhere--Every day is Veterans day

I

Source: Acuity-Insurance-flagpole; source Wikipedia

Thank you for all the men and women who have served, are serving and will serve.  NurseValue recognizes your commitment, service and sacrifices.  Thank you for allowing us to be free and live in a country of opportunity.

NurseValue is proud to announce our newest certified case manager,  Cortney Hubbard, RN, CCM.  Cortney joined us in 2010.  She has been a very busy since that time.  Cortney became a certified professional coder (CPM) and then went on to complete nursing school and obtained her RN licensure.  She has done so much in the last 5 years while continuing to be an asset not only to NurseValue but to every client she works with.  Please join us in celebrating Cortney's long list of accomplishments!

I am excited to be part of the new second edition of the Path to Legal Nurse Consulting. I provided one of the chapters.

Wherever you are on the path to legal nurse consulting career, you will benefit from these inspiring stories from successful LNCs. In this new second edition, Patricia Iyer tapped the expertise of her colleagues to bring you wit, wisdom, and lessons learned. The 42 chapters include updated chapters as well as 16 brand new chapters written by legal nurse consultants who are independents, expert witnesses and in-house consultants. The book is chock full of advice, encouragement, and humor.

Get your copy of this book at a special prepublication price of $20. Order at this link to get this price: www.legalnursebusiness.com/Path.

Vaccination Schedule 7-18 years

http://www.cdc.gov/vaccines/who/teens/downloads/parent-version-schedule-7-18yrs.pdf

Vaccination Schedule for birth to 6 years of age

https://www.healthychildren.org/Documents/tips-tools/Immunization%20Schedules/IZSchedule_Childhood.pdf

Osgood-Schlatter Disease

Providing taxi rides to and from practice for every sport offered to an adolescent, eating endless dinners in the car on the way to the practice field or a game, rearranging meetings at work to make sure I could make my taxi pick up at 4:00 pm and wiping the tears from my children after they lost a “game of a lifetime” were nothing compared to the day I had to explain Osgood-Schlatter Disease to my oldest son.

This young man didn’t know the definition of moderation.  Everything he did was higher, faster, longer, or it wasn’t worth doing.  He excelled in athletics from a very young age and loved every minute of practice, but competition was his real “high”.  This child took many hits and falls, but never acknowledged pain.  At age twelve he began to complain that his knees ached and that he was having difficulty sleeping because of the pain.  Having a nurse as a mother is not always the best thing for a boy.  I assumed he had just overdone it and encouraged him to take a hot bath and go to sleep. 

His complaints continued day after day.  He denied having had any high impact injury or having twisted his knees.  I have to admit that I was concerned when the achy feeling in one knee soon became an achy feeling in both knees.  I scheduled an appointment with his pediatrician just to make sure that everything was ok and that he just needed to rest.

X-rays of both knees were taken.  Blood tests were completed and Dr. Brown asked us to return to her office for a follow up visit.    Dr. Brown showed us the x-ray and told my son that he had Osgood-Schlatter Disease.

Osgood-Schlatter Disease is a condition causing pain and swelling at the tibial tuberosity.  The tibia is the large of the two lower leg bones.  The tibial tuberosity is the bump on the front of the tibia, just below the kneecap (patella).   The patellar tendon attaches the quadriceps to this bump or tuberosity.  In the adolescent the tuberosity does not yet have bony attachment to the rest of the tibia.  The mechanical attachment of the patellar tendon to the tuberosity is weak and occasionally causes separation of fragments of bone.  This separation causes pain and swelling in the teenager’s knee or knees.  Usually, this occurs in one knee, but research reveals that 25 % of the time both knee are affected.

My son’s daily athletic endeavors were just too much for his maturing knees.  Activities such as climbing stairs, running and deep knee bends increased his pain. 

The goal of treatment is to decrease the stress and inflammation at the tubercles.  My son was instructed to sit out of practice and games for the next two weeks.  He was given an anti-inflammatory medication to take three times a day and we were then to return to the doctor’s office for a recheck. 

All the way home, my son tried to convince me that the pain wasn’t that bad.  I listened and tried to calm his anger about being taken out of his beloved athletics.  Somehow my family made it through the next two weeks and we return for the follow up visit.  My son told the doctor that the pain was much better in both knees and pleaded to be able to return to his normal activity.  Dr. Brown recommended the anti-inflammatory medication be continued.  He was given permission to return to his regular activities, but was to take it easy for a while and not push his body “to its limits”.  Following any athletic work out he was to immediately ice both knees for twenty minutes.  He anxiously agreed to the treatment plan—anything to get back out on the field! 

My son’s pain slowly dissipated over a period of about three months.  He remained active and was able to do what he loved most-PLAY!  To this day I count my blessings.  Keeping this boy down was almost impossible and miserable for everyone in his life!  Osgood-Schlatter Disease may last over a period of months or years.  It may reoccur intermittently up until about age eighteen at which time the tuberosity fuses to the tibia.

If conservative treatment does not end the pain and swelling, it may be necessary to completely rest the knee or knees with a knee immobilizer or cast.  Luckily, this type treatment is rarely necessary.  The very best news is that Osgood-Schlatter Disease rarely causes any permanent injury except for an enlarged tuberosity (a larger protrusion on the lower portion of the knee).