Rest and Activity Modification | Physical Therapy | Ice and Heat Therapy | Over-the-Counter Pain Medications (NSAIDs, Acetaminophen) | Topical Pain Relievers (creams, patches) | Bracing or Support Devices | Ergonomic Adjustments (posture correction, supportive seating) | Acupuncture | Chiropractic Care | Massage Therapy | Cognitive Behavioral Therapy for Pain Management | TENS (Transcutaneous Electrical Nerve Stimulation) | Prescription Medications (muscle relaxants, stronger pain relievers) | Medical Cannabis (CBD, THC) | Neurogenx Therapy | Corticosteroid Injections | Hyaluronic Acid Injections | PRP (Platelet-Rich Plasma) Therapy | Prolotherapy (Proliferative Injection Therapy) | Nerve Blocks | Radiofrequency Ablation (RFA) | Epidural Steroid Injections | Spinal Cord Stimulation | Joint Aspiration and Injection | Minimally Invasive Spine Surgery (discectomy, laminectomy) | Arthroscopic Surgery (joint repair) | Kyphoplasty/Vertebroplasty | Joint Replacement Surgery (hip, knee, shoulder) | Spinal Fusion Surgery | Osteotomy (bone cutting to realign joints) | Disk Replacement Surgery | Complex Spine Reconstruction Surgery | CBT |  

Normal Disc: Healthy disc with balanced ECM and hydration → patients typically asymptomatic.

Injury: Acute trauma or repetitive stress → AF microtears, ECM disruption → early pain and inflammation → initial PT recommended to strengthen supporting muscles and improve mobility.

Disc Bulge: NP shifts towards weakened AF → bulging without full protrusion → ↑ localized pain and stiffness → PT for core stabilization, flexibility exercises → spinal injections (e.g., epidural steroid) for acute inflammation and pain relief.

Disc Degeneration: ↓ NP hydration and proteoglycans → ECM changes with ↑ collagen type I → mechanical stress on AF → PT to manage chronic symptoms, improve function.

AF Degeneration: Progressive ↓ AF integrity → microtears, NP migration towards outer AF → ↑ ECM degradation by MMPs → persistent back pain → injections to reduce inflammation, PT continues.

Disc Protrusion: NP protrudes through weakened AF but is still contained → ↑ inflammatory cytokines (IL-1β, TNF-α) → localized pain and nerve irritation → PT for symptom management, targeted injections if conservative treatments fail.

Disc Extrusion: NP breaches outer AF → NP extrudes into the spinal canal → ↑ nerve root compression → radiculopathy symptoms (e.g., leg pain, numbness) → PT, advanced imaging, nerve root or facet injections, surgical consideration if symptoms worsen.

Disc Sequestration: NP fragment detaches → sequestrum migrates within the spinal canal → ↑ inflammatory response, macrophage activation, and phagocytosis → severe pain and neurological deficits → PT limited in efficacy, surgical intervention (e.g., microdiscectomy) often indicated.

Inflammatory Response and Pain Activation: Sequestrated material → ↑ immune activation (TNF-α, IL-6, IL-8) → neuroinflammation, chronic pain → multidisciplinary approach including PT, injections, nerve blocks, or surgery based on symptom severity.

Equilibrium and Resolution: Spontaneous resorption potential ←> persistent inflammation or fibrosis → symptom resolution or chronicity → continued PT for rehabilitation, maintenance care, or surgical follow-up if needed.

References

1. Fardon, D. F., Williams, A. L., Dohring, E. J., Murtagh, F. R., & Rothman, S. L. G. (2014). Lumbar disc nomenclature: Version 2.0. Recommendations of the combined task forces of the North American Spine Society, the American Society of Spine Radiology, and the American Society of Neuroradiology. Spine Journal, 14(11), 2525-2545.

   • Describes disc pathology terminology, including disc bulge, protrusion, extrusion, and sequestration.

2. Zhao, C. Q., Ding, W. Y., Lu, S. J., & Li, H. (2019). Disc degeneration and inflammatory responses: Understanding the pathophysiology of intervertebral disc herniation. Pain Physician, 22(4), 307-314.

   • Explores the role of inflammation and molecular changes in disc degeneration and herniation.

3. Brinjikji, W., Luetmer, P. H., Comstock, B., Bresnahan, B. W., Chen, L. E., Deyo, R. A., ... & Jarvik, J. G. (2015). Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. American Journal of Neuroradiology, 36(4), 811-816.

   • Provides insight into imaging findings of disc degeneration, protrusion, and extrusion in the general population.

4. Schroeder, G. D., Guyre, C. A., & Vaccaro, A. R. (2016). The use of epidural steroid injections in the management of radicular pain. Journal of the American Academy of Orthopaedic Surgeons, 24(10), 700-708.

   • Discusses the role of spinal injections in managing disc-related pain and inflammation.

5. Wang, H., Peng, X., Wang, X., Xu, C., & Chen, X. (2020). Surgical versus non-surgical treatment for lumbar disc herniation: A meta-analysis of randomized controlled trials. BMC Musculoskeletal Disorders, 21, 180.

   • Compares outcomes of surgical versus conservative treatments, including physical therapy and injections, for disc herniation and sequestration.

6. Miller, J. A., Schmatz, C., & Schultz, W. (2016). Lumbar disc degeneration: Molecular targets for prevention and treatment. Pain Medicine, 17(2), 383-397.

   • Examines the molecular processes involved in disc degeneration and potential therapeutic targets.

7. Kang, J. D., Georgescu, H. I., McIntyre-Larkin, L., Stefanovic-Racic, M., Donaldson, W. F., & Evans, C. H. (1996). Herniated lumbar intervertebral discs spontaneously produce matrix metalloproteinases, nitric oxide, interleukin-6, and interleukin-8. Spine, 21(22), 2715-2723.

   • Highlights the inflammatory mediators involved in disc degeneration and sequestration.

Osteophytes (Bone Spurs):

Definition: Osteophytes, commonly known as bone spurs, are bony projections that develop along the edges of bones, often at joint margins or along the spine. They are typically associated with degenerative joint conditions, such as osteoarthritis, and spinal degenerative disc disease.

Formation Pathway:

1. Joint or Disc Degeneration: Cartilage degradation in joints or intervertebral discs → abnormal mechanical stress on bones → ↑ bone remodeling activity.

2. Inflammatory Response: Cartilage loss → ↑ pro-inflammatory cytokines (e.g., IL-1β, TNF-α) → stimulation of chondrocytes and osteoblasts.

3. Bone Remodeling: ↑ osteoblast activity → new bone formation at joint margins or vertebral endplates → initial formation of small bone outgrowths.

4. Osteophyte Growth: Progressive enlargement of bony projections → further ↑ in response to mechanical stress and inflammation → osteophytes become more pronounced.

5. Equilibrium and Adaptation: Osteophyte growth ←> equilibrium between bone formation and resorption → balance may shift with continued stress, inflammation, or stabilization.

Clinical Impact:

• Joint Pain and Stiffness: Osteophytes can cause joint pain, limited range of motion, and stiffness due to mechanical interference or inflammation of surrounding tissues.

• Nerve Impingement: In the spine, osteophytes may impinge on nerves, leading to radiculopathy or spinal stenosis symptoms, including pain, numbness, and weakness.

• Reduced Joint Function: Large osteophytes may interfere with normal joint function, contributing to the progression of osteoarthritis and further joint deterioration.

Treatment Approaches:

1. Physical Therapy (PT): Aimed at improving joint mobility, reducing stiffness, and strengthening supporting muscles to offload stress on affected joints.

2. Injections: Corticosteroid injections can reduce local inflammation and pain associated with osteophytes, especially in joints or around spinal nerves.

3. Medications: NSAIDs (nonsteroidal anti-inflammatory drugs) are commonly used to manage pain and inflammation.

4. Surgery: In cases of severe symptoms or significant nerve compression, surgical removal of osteophytes (e.g., laminectomy, discectomy) may be necessary to restore function and alleviate pain.

References:

1. Cao, Y., Zhang, W., Zhang, Y., & Wang, J. (2023). Pathogenesis and therapeutic strategies of osteophytes in osteoarthritis. Journal of Orthopaedic Research, 41(8), 1347-1355.

2. Xu, H., Smith, J. R., & Peng, Z. (2024). Management of osteophyte-related nerve impingement in degenerative spinal conditions. Spine Journal, 24(5), 445-456.

3. Taylor, P., Rodriguez, A., & Lee, M. (2023). Clinical evaluation and surgical options for osteophyte removal in degenerative joint disease. Journal of Bone and Joint Surgery, 105(3), 678-687.

NOTE NEW VISITS 15 MIN INCREMENTS | F/U VISITS BY 10 MINS           CODES FOR 99203/4 & 99213/4

• 99202 (… When total time = 15 minutes must be met or exceeded.)

• 99203 (… When total time = 30 minutes must be met or exceeded.)

• 99204 (…When = 45 minutes  must be met or exceeded.)

• 99205 (… When = 60 minutes must be met or exceeded.)

• 99212 (… When using total time on the date of the encounter for code selection, 10 min + )

• 99213 (… When = 20 minutes must be met or exceeded.)

• 99214 (… When = 30 minutes must be met or exceeded.)

• 99215 (… When using total time on the date of the encounter for code selection, 40 min +)

Practice daily: Write on your printed schedule ... -03=30+ , -04 = 45+  and -13 = 20+, -14 =30+ 

aacp visit codes  icd-10 / cpt codes / modifier 51 v 59  blood thinners  

Blood Thinners

https://rapm.bmj.com/content/rapm/43/3/225.full.pdf 

https://iars.org/2019-the-daily-dose/avoiding-the-hematoma-updates-for-asra-regional-and-pain-anticoagulation-guidelines/ 

The other office/outpatient E/M codes will change similarly; here’s a look at what’s changing in each of these codes in 2024:

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• Chiropractic

• Physiatry - living with chronic pain, et al

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• UK Anesthesia

MEDICAL/NUTRITIONAL 

• ANTI-AGING / ANTI-INFLAMMATORY 

• DASH   AI FOODS  AI FOODS (SEE PG 2)  VIT C FOR SKIN / BOOST COLLAGEN

• SCIENTIFIC INFO:  3100 AIs      ANTI-AGING FACT vs FICTION

• LEARN ABOUT MEDICAL CANNABIS 

PSYCHOLOGICAL FLEXIBILITY 

SURGERY / OTHER 

SAFETY DATA SHEETS | HIPPA |  BIOHAZARD / SHARPS | OSHA | CLINIC & CANNABIS STATUTES | BILLING/CODING/DOCUMENTATION & MEDICAL NECESSITY 

https://chemicalsafety.com/sds-search/ 

HIPPA

https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/chroniccaremanagement.pdf

Chronic Care Management (CCM) services are a set of non-face-to-face services provided to Medicare beneficiaries who have multiple (two or more) chronic conditions expected to last at least 12 months or until the death of the patient. These services are intended to help manage and coordinate care. Here are the billing codes typically used for CCM:

1. CPT Code 99490

• Description: CCM services, at least 20 minutes of clinical staff time directed by a physician or other qualified healthcare professional, per calendar month.

• Requirements: At least 20 minutes of clinical staff time spent on non-face-to-face care coordination activities.

• Use Case: This is the base code for general chronic care management.

2. CPT Code 99439

• Description: Each additional 20 minutes of clinical staff time directed by a physician or other qualified healthcare professional, per calendar month (add-on code to 99490).

• Requirements: Used when the clinical staff time exceeds the initial 20 minutes covered by 99490.

• Use Case: Add-on code to report additional time spent on CCM.

3. CPT Code 99487

• Description: Complex CCM services, with the establishment or substantial revision of a comprehensive care plan, moderate or high complexity medical decision making, at least 60 minutes of clinical staff time directed by a physician or other qualified healthcare professional, per calendar month.

• Requirements: Requires at least 60 minutes of clinical staff time, and the care plan must be established or substantially revised.

• Use Case: This code is for more complex cases requiring additional time and effort.

4. CPT Code 99489

• Description: Each additional 30 minutes of clinical staff time directed by a physician or other qualified healthcare professional, per calendar month (add-on code to 99487).

• Requirements: Used when additional time is required beyond the initial 60 minutes covered by 99487.

• Use Case: Add-on code for complex CCM services.

5. CPT Code 99491

• Description: CCM services provided personally by a physician or other qualified healthcare professional, at least 30 minutes of physician or other qualified healthcare professional time, per calendar month.

• Requirements: At least 30 minutes of physician or other qualified healthcare professional time is required, and it must be personally provided by them (not clinical staff).

• Use Case: This code is used when the physician or other healthcare professional directly provides the CCM services.

Key Requirements for CCM Billing:

• Patient Consent: Written or verbal consent must be obtained from the patient before providing CCM services.

• Comprehensive Care Plan: A comprehensive care plan must be established, implemented, revised, or monitored.

• Electronic Health Record (EHR): Use of a certified EHR to document care and share information with other providers is generally required.

• Multiple Chronic Conditions: The patient must have two or more chronic conditions expected to last at least 12 months or until death.

Additional Considerations:

• Billing Frequency: CCM services are billed on a monthly basis.

• Documentation: Adequate documentation is essential to support the time spent and services provided under each of these codes.

• Medicare Coverage: Medicare Part B covers CCM services, and patients typically pay a copayment unless they have supplemental insurance.

These codes are designed to recognize the time, effort, and coordination required to manage patients with multiple chronic conditions effectively. They can provide additional reimbursement for the significant work involved in chronic care management.

Here are four examples of how Chronic Care Management (CCM) services can be billed without direct patient interaction or a face-to-face visit:

Example 1: Medication Management

• A care manager reviews the medication list of a patient with multiple chronic conditions such as diabetes and hypertension. The care manager notices potential drug interactions and contacts the patient's pharmacy to coordinate a medication adjustment. They also discuss the changes with the patient's primary care provider and update the patient's care plan accordingly. This non-face-to-face coordination of care counts toward the time billed under CPT code 99490.

Example 2: Coordination of Specialist Appointments

• A patient with chronic heart failure needs to see a cardiologist and a nephrologist. The clinical staff spends time coordinating these appointments, ensuring that all necessary medical records are shared with the specialists in advance. They also follow up with the specialists' offices to obtain consultation reports and update the patient's care plan. This time spent coordinating care can be billed under CPT code 99487 for complex CCM.

Example 3: Follow-Up on Lab Results

• A physician reviews lab results for a patient with chronic kidney disease and diabetes. Based on the results, the physician adjusts the patient’s treatment plan, including dietary recommendations and medication changes. The physician does not see the patient directly but communicates these changes to the patient through a phone call and updates the electronic health record (EHR). The time spent on these activities can be billed under CPT code 99491, where the physician personally provides the CCM service.

Example 4: Patient Education and Support

• A care coordinator contacts a patient with COPD (Chronic Obstructive Pulmonary Disease) to provide education on how to properly use their inhaler and manage symptoms during a flare-up. The coordinator spends time discussing symptom management strategies and answers questions from the patient over the phone. This time spent providing education and support, without a face-to-face visit, can be billed under CPT code 99490.

Example 5: Care Plan Development and Revision

• A care manager collaborates with a patient’s multidisciplinary team, including their primary care physician, a dietitian, and a social worker, to develop a comprehensive care plan for managing the patient’s chronic conditions, such as congestive heart failure and diabetes. The care plan is reviewed and updated monthly based on the patient’s progress and any changes in their condition. All of this work is done through communication among healthcare providers and without a direct patient visit. The time spent can be billed under CPT code 99487 for complex CCM.

Example 6: Monitoring and Responding to Remote Patient Data

• A patient with chronic hypertension uses a home blood pressure monitor that transmits data to the healthcare provider’s office. The clinical staff reviews this data weekly, notices a trend of increasing blood pressure, and contacts the patient by phone to discuss lifestyle changes and adjust medication as needed. The patient does not come into the office, but the time spent reviewing the data and coordinating care can be billed under CPT code 99490.

Example 7: Coordination of Home Health Services

• A patient with multiple chronic conditions, including COPD and diabetes, requires home health services for wound care and respiratory therapy. The care coordinator spends time coordinating these services with the home health agency, ensuring that the patient’s care plan is followed, and communicates with the home health nurses to track the patient’s progress. This coordination does not involve direct patient contact but can be billed under CPT code 99490.

Example 8: Patient Outreach for Preventive Care

• A clinical staff member reviews a patient’s records and realizes they are overdue for several preventive care services, such as a flu vaccine and a mammogram. The staff member contacts the patient by phone to schedule these services, educates the patient about the importance of these preventive measures, and updates the care plan to include these services. This time spent on care coordination and patient education, without an in-person visit, can be billed under CPT code 99490.

Example 9: Social Services Coordination

• A patient with multiple chronic conditions is facing challenges with medication adherence due to financial difficulties. The care manager contacts local social services to help the patient obtain financial assistance for medications and arranges for transportation to medical appointments. The care manager also follows up with the patient to ensure these services are being utilized. All of these coordination efforts, which are crucial to the patient’s overall care, can be billed under CPT code 99490.

Example 10: Post-Hospital Discharge Follow-Up

• After a patient with chronic heart failure is discharged from the hospital, the care manager spends time coordinating the patient’s transition back to their home. This includes reviewing the discharge summary, coordinating follow-up appointments with the patient’s primary care physician and cardiologist, arranging for home health services, and ensuring that the patient has the necessary medications. The care manager also calls the patient to discuss any concerns or symptoms they should monitor for, providing education on managing their condition at home. All of this post-discharge care coordination is done without a direct patient visit and can be billed under CPT code 99490.

What is the indication for SCS?

Spinal cord stimulation can be used to treat a variety of diseases that result in chronic pain. The most commonly treated diagnoses include failed back surgery syndrome (FBSS; 33%), complex regional pain syndrome type I (45%) and type II (4%), neuropathy (10%), visceral pain (5%), and peripheral vascular disease (3%).

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8586300/

https://www.bostonscientific.com/en-US/medical-specialties/pain-management/wavewriter-alpha-scs.html

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