Exploring Modifier 58: Post-Operative Method

This service was provided during the postoperative period for a previous related procedure conducted by the same surgeon.

The first edition helped reassure the use of customary terms and clarifications to record procedures in the medical documents; delivered the foundation for a computer based system to assess and evaluate operational procedures; facilitated effective communication as precisely as possible for the data related to procedures and services to organizations connected with insurance claims and conveyed uncomplicated data for analyzation and statistical commitments. This first edition focused on procedures for surgeries and touched on some degree of laboratory, radiology, and prescription techniques. These restrictions encouraged the delivery of the second edition of CPT just four years later in 1970. With this subsequent publication there was a heightened

Client outcome: have surgical area that show evidence of healing no redness, draining, or immobility _______________________________________________________

Current Procedural Terminology (CPT) is published by the AMA and updated yearly. This terminology was devised to have a standard language of defining medical and surgical procedures for billing purposes. Insurances use this information to evaluate and decide on the proper amount of reimbursement (Wager et al., 2009).

I strongly believe that one of the main purposes of this book is for the author, Ishmael, to educate his audience on one of the negative impacts of war that strongly impact children, the loss of their innocence. He demonstrates this through his personal experiences and his loss. For example at the beginning of the book, Ishmael is living a normal life and is like any other kid, living an innocent life and never having been exposed to violence. This is evidenced on page 23 as Ishmael explains how he felt as the rebel attack took place in his town. He confessed “The sounds of the guns was so terrifying it confused everyone…….My

The physician performs a problem focused history and physical examination with straightforward decision making 99201

Like others in New York, you may have, at one point or another, needed surgery to repair internal damage or treat a medical condition, among other reasons. When undergoing such procedures, you, and other patients, put your life and wellbeing in the hands of your medical provider. All too often, however, surgical errors occur that could be prevented.

In order to submit with the use of modifier -22, Increase Procedural Services, the medical record must contain documentation that substantiates that the service was unusual in some way such as statements about increased risk to the patient, the difficulty of the situation. For example: Excessive blood loss, Extensive well-documented adhesions in abdominal surgery, Trauma extensive enough to complicate the procedure and the complication is not reported separately, The service rendered was significantly more complex than described in the code description and/or other pathologies, tumors, malformations that directly interfere with the procedure but are not reported

In the political cartoon with the pilgrim and native Americans the image shows a gun held to the pilgrims head. in the picture the pilgrim ask the native to pass the water.This was not what probably happened at the first thanksgiving ,and despite the small bit of humor that goes along with the image it has a deeper meaning. The native american in the image is wearing a shirt with the words NO DAPl. This is a ongoing issue with a pipeline that is trying to be built on a native american territory known as standing rock.The pilgrim in the picture is the government in the picture trying to take the land by force. The water in the picture is represent as the land or what is own by the natives. In the picture you see that the government is threatening

The second step is the major diagnostic category determination in which the principal diagnosis is assigned to an encounter for one of the 25 MDCs (Casto & Forrestal, 2015). The 3rd step is the medical/surgical determination to determine whether a procedure was performed and can be assigned a surgical status (Casto & Forrestal, 2015). The MS-DRG Definitions Manual and many of ICD codebooks verifies which procedures are valid or not valid (Casto & Forrestal, 2015). For example, minor procedures and testing do not qualify (Casto & Forrestal, 2015). Also, when a qualifying procedure is not performed, the case is assigned a medical status (Casto & Forrestal, 2015). The fourth step involves using different refinement questions to figure out the correct MS-DRG assignment (Casto & Forrestal, 2015). Therefore, once the medical and surgical classification groups for an MDC are formed, each class of patients is evaluated to determine if complications, comorbidities, the patient’s age or discharge status consistently affected the use of hospital resources (Design and Development,” n.d.).

During the assessment I was keen to make sure that the patient was clear about what the procedure involves and the routine of the day, throughout the assessment I was concerned that while I believe the patient did understand the Procedure, I was concerned as to whether all the possible complications and post procedure instructions were fully understood, I was also concerned as to whether the patient had the ability to communicate any concerns she may have, the patient also has hypertension. The priorities of care with this patient is monitoring her blood pressure throughout her time within the unit, the ability to understand the procedure and capacity to consent, also communication barriers both of which relate to her learning disabilities. I believe that the key priority for this patient is her learning disabilities and communication barriers, as it is vital that the patient is entirely aware of the procedure.

After it is determined the patients are in recovery from serious illnesses and surgical episodes the potential for complications is still present, and those patients still require a higher level of nursing intervention than is typically offered in a skilled nursing

For established patients receiving evaluation and management, providers may bill for these services using the CPT codes 99212, 99214. Choosing the correct code depends on the patient’s history, examination findings, and decision-making complexity. If complexity is found to be straightforward taking the provider less than 10 minutes, the billing code will be 99212 (Engle, 2014). If the history and examination findings result in moderate decision-making complexity, requiring more time from the practitioner and more diagnostic procedures the billing code will be 99214 (Engle, 2014). While, Ms. Trinidad does not encounter established patients in the emergency department, within my clinical hours, Ms. Rossow encountered several established patients of various levels of complexity. The billing code 99212 is appropriate to use for patients with low complexity, such as one of Ms. Rossow’s patients whose visit was due to elbow pain after a fall a week ago. Mrs. Rossow also managed the care of patients with a higher level of complexity such as a middle-aged male with a history of recent prostate cancer and a chief complaint of abdominal pain and fever.

According to the CDC, in the United States there have been 51.4 million inpatient procedures performed. This shows how relevant surgery is, it is very common for a person in the U.S. to have a procedure

The developmental physiology is heavily affected by the culture, gender and the age of the subject. All three of these factors takes a huge role in developing an individual. Fist the age of the individual is very important. The age affects how much the individual is affected by the outside world, giving the nature and nature more effect on a younger individual then say an older individual. This reasoning has led to many of the theories in developmental phycology to be based around early adolescence, as this is the time of their lives that they can be most easily manipulated and changed depending on their surroundings. During this crucial time in the development of the individual, the gender and culture aspects of the child’s life has a large effect on the developmental phycology, the cultural aspect affect the development as different cultures have different parenting styles, which can either have a positive or negative effect on the child, as well as racial stereotypes possibly leading to detrimental effects of the child’s development.