In Part 1 of this series, we covered the vital role of medical decision making in determining the final level to bill for a patient encounter. Medical decision making is the key component in coding because it reflects the intensity of the provider’s cognitive labor. This implies that there’s an unseen component involved in the…
A recent study, conducted by the Vasculitis Clinical Research Consortium and funded by the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), examined whether the addition of abatacept, a drug that affects T cell activation, to standard prednisone treatment could reduce the risk of relapse in patients with giant cell arteritis (GCA).1 Although…
Treatment with oral methylprednisolone may be associated with an increased risk of serious adverse events, specifically infection, in patients with IgA nephropathy. Despite the five-times higher risk, study results also showed a three-times lower risk of kidney failure for the treatment group…
For years, guidelines from various organizations have recommended osteoporosis screening in women and men starting at a specific age or based on specific risk factors. Among these guidelines are those developed by the U.S. Preventive Services Task Force (USPSTF) that recommend universal osteoporosis screening for women 65 years of age and older and for targeted…
“Man may be the captain of his fate, but he is also the victim of his blood sugar.” —Wilfrid Oakley, MB BChir, an early pioneer in diabetes care Perusing the list of the most notable medical achievements in the 20th century, a reader may conclude that the discovery of insulin should rank in a category…
Opana ER Pulled from U.S. Market Last month, the U.S. Food and Drug Administration (FDA) asked Endo Pharmaceuticals to remove oxymorphone hydrochloride extended release (Opana ER) from the U.S. market due to public health consequences related to abuse. The agency has concerns that the risks presented by the treatment do not outweigh its benefits.1 On…
The AMA House of Delegates (HOD) met in Chicago for its annual meeting June 9–14. More than 530 HOD members were present, with several hundred AMA and association staff and guests. As I am sure you have noted from past issues of ACR@Work, the ACR is in its five-year membership review. The ACR must be…
Romosozumab’s Future Is Uncertain Romosozumab, which has the possible U.S. brand name Evenity, is awaiting approval from the FDA.1 The treatment is an investigational, injectable biologic for treating osteoporosis. It increases bone formation and bone density, reducing a patient’s risk of fractures. The manufacturer no longer expects the FDA to approve the drug this year…
This year the ARHP Clinical Focus Course brings together experts in the field to provide an interprofessional approach to the management of systematic lupus erythematosus (SLE) to improve patient outcomes. The daylong course, titled Systemic Lupus Erythematosus: Taming the Wolf—Salient Lessons from Practice and Research, which is offered on Nov. 4, will provide a case-based…
The levels of service within an evaluation and management (E/M) visit are based on the documentation of key components, which include history, physical examination and medical decision making. The history component is comparable to telling a story and should include a beginning and some form of development to adequately describe the patient’s presenting problem. To…