Clinical Indicators: Endoscopic Sinus Surgery, Pediatric
History (one or more required) (The history must include specific symptoms and findings obtained by the otolaryngologist. A historical diagnosis labeled "sinusitis" by the patient or unsubstantiated symptoms alone is not sufficient documentation to establish this as a chronic illness). Failure of medical management…
Clinical Indicators: Endoscopic Sinus Surgery, Adult
History (one or more required) Chronic rhinosinusitis without nasal polyps (CRSsNP) with persistent symptoms and objective evidence of disease by endoscopic and/or CT imaging that is refractory to optimal medical treatment Chronic rhinosinusitis with nasal polyps (CRSwNP) with persistent symptoms and objective evidence…
Clinical Indicators: Endoscopic Debridement
History (one or more required after failure of mechanical therapy) Postoperative care of endoscopic sinus surgery Postoperative hemorrhage Postoperative exudate or discharge Complications of endoscopic sinus/skull base surgery Fungal sinusitis Physical Examination Complete anterior and posterior nasal examination (rhinoscopy after mucosal decongestion (one…
Clinical Indicators: Diagnostic Nasal Endoscopy
*Note: Separate Procedure by CPT definition means the code should not be reported with other procedures of which it is a part; in this case, therapeutic nasal/sinus endoscopic procedures. History (one or more required) Obstructed nasal breathing Epistaxis, anterior or posterior, either active…
Clinical Indicators: Neck Dissection
*Note: Radical neck dissection performed in conjunction with removal of a primary malignancy is coded with the primary; in some instances a single CPT codes describes both, eg CPT 31365for total laryngectomy with radical neck dissection whereas in others, each must be coded separately…
How to Avoid Implicit Bias When Treating Women
Throughout history, certain women’s health complaints were often diagnosed as “female hysteria”– a term implying “it’s all in her head.” When presented with unexplained neurological complaints, women are 10 times more likely to be diagnosed with conversion or somatoform disorders, the modern…
How to Avoid Implicit Bias When Treating Transgender Patients
Transgender is a term for a diverse community—such as trans women (male-to-female) and trans men (female-to-male), gender queer individuals, and those whose gender identity or expression differs from the societal expectations of how they should look, act, or identify…
How to Avoid Implicit Bias When Treating Spanish-Speaking Patients
With the dramatic increase in patients for whom English is not their native language, physicians can be challenged in terms of providing high-quality healthcare and maintaining patient safety. Growing evidence shows language barriers indirectly impact the quality of healthcare patients receive. Language barriers…
How to Avoid Implicit Bias When Treating Obese Patients
When compared with adults at a healthy weight, obese individuals have an increased risk of developing serious health conditions including hypertension; Type 2 diabetes; heart disease and stroke; sleep apnea and breathing problems; some cancers; and mental illness such as depression and anxiety. Obese…
How to Avoid Implicit Bias When Treating Patients with Cultural Dress
The diversity of different religions and cultural norms can create challenges for healthcare teams to better understand how cultural competence impacts care. If the healthcare team is not working together to provide culturally competent care, patients are often left uncomfortable which can impact patient…
How to Avoid Implicit Bias When Treating: Patients from Rural Areas
Stereotyping in medicine has serious consequences. Patients who feel judged by healthcare workers are less likely to follow medical instructions and more likely to mistrust their healthcare providers, are less likely to access readily available preventive care and put off treating health problems. In…
How to Avoid Implicit Bias When Treating Older Patients
Discrimination against older adults has an impact on the well-being of those citizens and is a potential barrier to health equality. Studies indicate that physicians may involve older patients in medical decisions less frequently, show less patience and respect, and act less involved…
How to Avoid Implicit Bias When Treating LGBTQ Patients
The percentage of American adults identifying as lesbian, gay, bisexual, transgender, or queer, commonly referred to as LGBTQ, is rising. Studies have shown half of all respondents have experienced a healthcare provider’s refusal to provide care or touch the patient; using excessive precautions…
How to Avoid Implicit Bias When Treating Black, Indigenous, and People of Color (BIPOC) Patients
Large health disparities persist between Black and white Americans. The National Academy of Medicine released a comprehensive study concluding poverty cannot account for the fact that Black people are sicker and have shorter life spans than their white counterparts. Many factors likely contribute to…
Clinical Indicators: Nasal Fracture (with or without septal fracture)
History (required) Recent nasal trauma with deformity Physical Examination (required) Evidence of nasal septal fracture (with or without concomitant nasal fracture) Description of complete intranasal examination with documentation of obstruction hematoma septal deviation septal perforation rhinorrhea (assess for CSF leak) Tests (not required but…
Clinical Indicators: Mandibular Fracture
History Trauma Malocclusion perceived by patient Trismus Airway patency concerns Physical Examination Evidence of fracture Palpate or visualize deformity Mandibular stability Assessment of occlusion Status of dentition Sensory deficit Evaluate airway Other coexisting fractures Mucosal lacerations over alveolar ridge surfaces Tests Radiographs Cervical spine…
Clinical Indicators: Le Fort Fracture
History Trauma, indicate mechanism of injury Clear rhinorrhea Visual problems Malocclusion/dental status Trismus Facial numbness Difficulty with sense of smell Physical Examination Nasal/oral bleeding Oral/facial lacerations Occlusal status (required) Eye exam, vision and extraocular mobility Airway compromise Facial hypesthesia/anesthesia Intracranial…
Clinical Indicators: Thyroidectomy
History (one or more required) Thyroid mass Family history of thyroid disease History and/or symptoms of hyper or hypothyroidism History of radiation to the neck History of accidental exposure to radiation History of medullary carcinoma in the family with positive RET oncogene or…