Medicine Health

Although I appreciate the value that traditional medicine brings to health care, I am passionate about a life-changing philosophy that speaks to the core of man and has been proven through the ages. This philosophy differentiates the kind of medicine I practice from that which most physicians practice.

The body is a self-healing organism. It needs the nutrients and building blocks in order to perform its designed functions. There are many interferences with this process. When toxic substances are removed, then your body can use the nutrients to perform its maximal function. Allopathic medicine looks at your body as a mechanical machine that breaks down, so the physician must "fix it." 

Here are some more challenging philosophical comments to ponder.

What I've done is take the conventional (also called allopathic) medicine philosophies and compare them side by side with alternative medicine (also called integrative, complementary, or preventive medicine).

Actually, no name is fully descriptive for either of the disciplines. Conventional could just as easily refer to medicine that was practiced in the past, now called complementary or alternative medicine. And alternative medicine could just as easily refer to the surgical/drug alternatives that you resort to when your homemade remedies do not help.

Alternative Medicine

The body is self-healing - but only if nutrients and building blocks are present and toxic substances are removed.

Treat cause.

Work with the physiology of the body.

Build the terrain (cells) and strengthen the natural defenses of the body.

Based on the science of biochemistry and physiology.

The body has an energy force, chi, spirit, soul that is separate from the physical body, from the physical body, responding to Einsteinian physics.

Use whole, organic products or bioidentical products.

Emphasize safer herbs, minerals, vitamins.

Different view of same disease.

Use safer procedure for same disease.

Use non-invasive testing whenever possible.

Treat "untreatable" diseases.

Conventional Medicine

The body is a mechanical machine that breaks down, so the physician must "fix" it.

Treat symptoms.

Control the physiology of the body.

Kill the enemy.

Heavily influenced by pharmaceuticals, driven by consensus, tradition, policy, insurance, randomized, double-blind, placebo-controlled studies.

The body is a biochemical, physical entity with pulleys, organs, and vessels that follow Newton's laws of physics.

Use synthetically changed, patentable products.

Emphasize medications.

It's not too hard to determine my bias, is it? However, it's important to note that I practiced conventional, allopathic medicine for more than 20 years before realizing that there were some significant factors in alternative medicine that I was overlooking, all in the name of staying "within the box." Current research tends to show that alternative medical approaches work. From my clinical experience, I see that to be true on a daily basis.

For example, if you come into a conventional medical doctor's practice, complaining of migraines headaches, conventional medicine would send you on your way with a prescription, or maybe several prescriptions. Try one, see if it works, get back with me in a few weeks. As an alternative, integrative, or complementary physician, my first questions are: "What factors trigger the migraine? What is your current emotional situation? What stresses are you dealing with right now, or what have you dealt with in the past?" I get a solid history, and then we just crank out the reasons and causes for migraines. I base my treatment on the triggering causes, thus making my treatment one that deals with the core issues rather than the end organ symptoms.

Let's insert one more thing onto the alternative side of the chart: balance. I'm not putting it in the chart, because it's something I want you to think about and rediscover for yourself. It's good to take good things into your body, but too much of a good thing can be very harmful. Too little of a good thing is also harmful. Too much of one thing may cause an imbalance that may be just as harmful as an excess or deficiency. For instance, all the vitamins are very helpful, but to take one in isolation, especially at high doses, may cause an imbalance in your body and be detrimental to it. Others have used the term "moderation" to describe keeping a balance.

Balance applies to everyone, whether you embrace alternative medicine or conventional medicine. Balance will lead you ultimately to discovering what your body is telling you it needs to be dynamically healthy. Balance will put you in the position where you are able to hear your body, understand it, apply what you learn, and feel the difference.

To your dynamic health and energy! (And keep your balance!) Warm Regards, Dr. Stan Gardner

© Copyright 2008 Stan M. Gardner, M.D. All rights reserved. http://www.stangardnermd.com

Many providers find coding Preventive Medicine (Health Assessments) and Office Visits very confusing. In fact, many feel that it is not worth it. It seems simple enough, an established 34-year-old male patient comes in for their annual health assessment and also have other conditions like HTN, Diabetes Mellitus and Hyperthyroidism that were addressed. Why shouldn't I be able to use a Preventive Medicine code (99395) with at least a low-level established patient visit (99213) and modifier 25?

Well your partially right. See, a Health Assessment is.... well exactly that. It is an assessment of your patients overall health. The extent and focus of the services will largely depend on the age of the patient. When a provider conducts a health assessment it is expected that the provider will chart a comprehensive age and gender appropriate history /exam. At this time I would like to explain the term "comprehensive". As you may be aware, Office visits have Comprehensive history and exams too. However, Comprehensive in a Health Assessment (99381-99397) is not synonymous with comprehensive exam in an office visit (99201-99215). Meaning, the Nature of the presenting problem dictates the elements in your history, exam and medical decision-making for office visits. In other words, if a patient presents for a splinter on a finger, a comprehensive history and exam should not have to be attained to gather the information, and the medical decision-making should only show the necessary treatment for removing a splinter (Always remember medical necessity). Other important facts about health assessment are anticipatory guidance, risk factor reduction interventions or counseling, and management of insignificant problems.

So, what should you do when you have a patient with an acute condition (chest pain) and/or chronic condition (HTN) presenting for an annual Health Assessment?

You should take a comprehensive history, comprehensive exam and order proper laboratory/diagnostic procedure. Now lets take a look at the acute and/or chronic conditions. Providers should ask themselves if the condition is requiring work up that is over and beyond their usual. Remember, documentation guidelines are not the same for health assessment. In other words, Health Assessments does not rely on a chief complaint or a history of presenting illness. Also, a health assessment is not problem oriented. Health Assessments rely on a comprehensive ROS (Review of Systems), a comprehensive PFSH and a comprehensive assessment of risk factors. Since you already documented a comprehensive history and exam, this would be considered overlapping. Therefore, the E/M reported for the problem visit (99201-99215) should be based on additional work performed by the provider in determining the best course of action in treating this problem.

Ask yourself, can this condition stand on its own? Is this condition significant enough to have its own encounter?

When using an office visit code (99201-99215) with a health assessment (99381-99397), a modifier 25 should be used to show the separately identifiable service that was performed within the annual exam.

Modifier point: Modifier 25 is used to show a significant, separately identifiable evaluation and management, service by the same physician on the same day of the procedure or other service. This modifier can only be appended with an E/M code.

Preventive Medicine Example:

34-year-old male comes in for routine annual visit. Patient is also noted to have HTN. HTN is stable w/ diet and medication. Patient has no complaints. A comprehensive history and exam is taken. Provider orders labs and tells patient to continue with current medication.

S: Patient here for annual follow-up. Patient has HTN. No complaints.

No f/c, chest pain, dyspnea, blurry vision, sore throat, n/v, allergies, lymph abnormalities, thyroid problems, urinary incontinence,

Medical hx: HTN

Family hx: father has DM

Social: non smoker, social drinker, married

O: 130/70, 96.7

HEENT: anicteric sclera, ENT: normal

Cardio: normal RRR

Lungs: Clear to Auscultation

Ext: good ROM, no abrasion, no edema, skin tight

Neck: no lad

Neuro: A&O x3,

GI: soft nontender, normal BS

Gu: Normal

Anticipatory guidance discussed about exercise and medication. Patient indicates understanding

Assessment: health checkup,HTN

Plan: Continue meds as ordered.

Dx(s): V70.0, 401.9

CPT: 99395

Preventive Medicine with office visit example:

52-year-old established patient presents for an annual exam. When you ask about his current complaints, he mentions that he has had mild chest pain and a productive cough over the past week and that the pain is worse on deep inspiration. No f/c, dyspnea on exertion, n/v. Remember, you are going to document additional history to support the exacerbated condition. Your exam is going to still comprehensive for the health assessment with extra documentation of the affected area(s) (Cardiovascular and Respiratory). An EKG and chest X-ray is ordered and reviewed. Your final diagnosis is acute bronchitis and chest pain.

Assessment: health checkup, Acute Bronchitis, Chest pain

Plan: Medication for Acute Bronchitis is prescribed.

Dx(s): V70.0, 466.0

CPT: 99397 (Health Assessment)

99213(Problem visit) -25 (Significant, separately identifiable service by same provider on same day)

93000 (EKG)

71020 (Chest xray, PA and lateral)

Please note, the above cases are examples only. As with all documentation, providers should always report the correct level of service by the documented history, exam and medical decision making. To find more examples of using preventive medicine codes with and without office visits, go to your respective medical societies; AAFP, ACOG, etc... They are ALWAYS a great resource for information!