Clinical Indicators: Laryngectomy
Clinical IndicatorHistory (all required) Symptoms--describe patient complaints of voice change, difficulty swallowing and/or breathing, hemoptysis, unexplained weight loss, throat pain or "lump in throat," and approximate date of onset. Amount and duration of smoking and alcohol use. Describe any previous treatment for complaint…
Clinical Indicators: Laryngoscopy/Nasopharyngoscopy
Clinical Indicator*If appropriate, a "-25" modifier must be added to the Evaluation and Management (E & M) code if this procedure is performed on the same date. History (one or more required) Persistent hoarseness. Suspected neoplasm of upper aerodigestive tract. Chronic cough. Chronic postnasal drainage. Recurrent…
Clinical Indicators: Inferior Turbinate Surgery
Clinical IndicatorHistory (required) Chronic nasal obstruction due in part to inferior turbinate hypertrophy. Failure of directed medical management with continued nasal symptoms (medications, allergy treatment, and duration of therapy). Failure of medical treatment of rhinitis medicamentosa. Symptoms of obstructive sleep apnea. Physical Examination (required) Inferior…
Clinical Indicators: Ethmoidectomy
Clinical IndicatorHistory (one or more required) Failure of optimal medical management (describe) for acute or chronic ethmoid sinusitis. Multiple or recurrent nasal polyps causing obstruction. Impaired sense of smell. CSF leak/encephalocele (31290 should include the ethmoidectomy) Orbital thyroid disease Trauma resulting in ethmoid scarring…
Clinical Indicators: Endoscopic Sinus Surgery, Pediatric
Clinical IndicatorHistory (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
Clinical IndicatorHistory (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
Clinical IndicatorHistory (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
Clinical Indicator*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
Clinical Indicator*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…