Walton Family Medicine

10/03/2025

Coding Clarified Medical Terminology Word of the Day!

Laminectomy
lam·​i·​nec·​to·​my
Surgical removal of the posterior arch of a vertebra (as to relieve compression of a spinal nerve root)

AI Overview
For laminectomies, you would use a CPT code like 63045 for a posterior extradural laminectomy and a relevant ICD-10 diagnosis code for the reason for the surgery, such as M48.06 for lumbar spinal stenosis. You may also need to use codes for conditions arising from a previous laminectomy, like M96.1 for postlaminectomy syndrome or M96.3 for postlaminectomy kyphosis.
CPT Codes (Procedures)
These codes describe the surgical procedure performed.
CPT 63045:
Posterior extradural laminotomy or laminectomy for exploration/decompression of neural elements or excision of herniated intervertebral disks.
Other CPT codes:
Other specific codes might apply depending on whether the laminectomy was performed for a re-herniation, was bilateral, or was performed in conjunction with another procedure like fusion.
ICD-10 Codes (Diagnoses)
These codes provide the reason for the laminectomy.
M48.06:
Spinal stenosis, lumbar region.
M51.16:
Intervertebral disc disorders with myelopathy, lumbar region.
M96.1:
Postlaminectomy syndrome, not elsewhere classified, for symptoms after a laminectomy.
M96.3:
Postlaminectomy kyphosis.
Important Considerations
Documentation is Key:
The specific CPT and ICD-10 codes depend on the surgeon's documentation, including the reason for the procedure and the specific findings.
Specificity:
Choose the most specific diagnosis and procedure codes to accurately reflect the patient's condition and the services provided.
Excludes Notes:
Always review Excludes1 and Excludes2 notes within the ICD-10-CM code set, especially for codes like M96.1 and M96.3, to ensure correct coding.

09/27/2025

We are so proud of 2 of our nurses, taking control of their health and winning 2nd and 3rd place in the Loganville Police donut dash today. Congrats Tammie Root Sharpe and Michele Pannell.

09/23/2025

Alright — let’s unpack HIPAA in the context of a parent trying to access an adult child’s health information, especially when that child has a brain disorder.
1. What HIPAA Actually Says

HIPAA (the Health Insurance Portability and Accountability Act) is a federal law that protects the privacy of a person’s medical information.
For adults (18+), parents are not automatically entitled to see their child’s medical records or talk to their doctors — even if the child still lives at home or the parent pays the bills.
Doctors and hospitals generally can only share health information with someone else if:

The patient gives permission (usually through a signed HIPAA release form).

It’s an emergency and the patient is unable to make decisions (called “incapacitated”).

State law gives special rights in certain situations.

2. HIPAA Pathways for Parental Access

Here are the main legal doors that might open under HIPAA:
A. Written Authorization

The adult child signs a HIPAA release form naming the parent as an “authorized representative.”

This can be broad (all medical information) or limited (just for one provider, one condition, or one time period).

Without it, the parent’s access will be restricted.

B. Involvement in Care

HIPAA allows providers to share relevant information with a family member if the patient agrees verbally, or if the provider decides it’s in the patient’s best interest and the patient does not object.

This is often used for care coordination — e.g., discussing medication schedules or hospital discharge plans.

C. Incapacity or Emergency

If the patient is unconscious, psychotic, or otherwise unable to communicate informed consent, HIPAA permits providers to share relevant information with someone involved in their care.

This is based on the provider’s professional judgment — but once the patient regains decision-making ability, the information flow stops unless they give consent.

D. Legal Authority (Overrides HIPAA Privacy)

Healthcare Power of Attorney (POA) — if the adult child has signed a POA naming the parent as agent, the parent can access records and make decisions if the child is incapacitated.

Guardianship/Conservatorship — court-appointed authority that gives legal rights to manage medical care, sometimes permanently.

Advance Directive — a document where the adult child specifies who can see their records and make decisions.

3. Special Challenge with Brain Disorders

Some brain disorders (e.g., schizophrenia, bipolar disorder, anosognosia) can cause the person to refuse consent because they don’t believe they’re ill.
This creates a legal brick wall unless:

The provider sees the patient as incapacitated at that moment, or

The parent already has a POA, guardianship, or court order.

4. Practical Tips for Parents

Have the conversation early — ask your adult child to sign a HIPAA release during periods of stability.

Targeted releases — sometimes people are more willing to allow limited sharing (e.g., only about medications, not full notes).

Emergency info — give your contact details to providers and state you’re involved in care; even without a release, they may contact you in a crisis.

Know state laws — some states give extra rights in mental health care situations.

Consider legal tools — consult an attorney about POA or guardianship before a crisis.

09/11/2025

08/22/2025

Coding Clarified Medical Terminology Word of the Day!

Rxternal os
es·​ter·​nal··​os
The opening of the uterine cervix into the va**na

To correctly code medical services related to the external os (the opening of the cervix into the va**na), you'll need to utilize both CPT (Current Procedural Terminology) codes and ICD-10 (International Classification of Diseases, 10th Revision) codes.
CPT codes
CPT codes describe the services and procedures performed by a healthcare provider.
For a standard pelvic examination that includes visualization and assessment of the external os, consider using CPT code +99459 (Pelvic examination).
It's important to note that CPT code +99459 is an add-on code, meaning it must be billed in conjunction with an associated Evaluation and Management (E/M) service.
Appropriate E/M codes to be used with CPT code +99459 include:
Office visits: 99202-99215
Consultation visits: 99242-99245
Preventive visits: 99383-99387, 99393-99397
CPT code +99459 specifically captures the practice expenses associated with performing a pelvic examination, such as clinical staff time for chaperoning and the cost of supplies.
If the examination of the external os is part of a more extensive procedure like a colposcopy with or without biopsy, consider CPT codes like 57410, 57420, or 57421, depending on the specifics of the procedure performed.
For procedures performed under anesthesia, such as an extensive examination or biopsy, other CPT codes may be necessary. CPT code 57410 for "Pelvic examination under anesthesia (other than local)".
ICD-10 codes
ICD-10 codes represent the diagnoses or reasons for the encounter.
The specific ICD-10 code will depend on the patient's condition or reason for the examination of the external os.
For conditions affecting the cervix uteri, including the external os, you would look to the N00-N99 chapter in ICD-10-CM (Diseases of the genitourinary system).
If the findings are normal or for routine screening purposes, codes from the Z00-Z99 chapter (Factors influencing health status and contact with health services) might be appropriate.
For example, N88.8 could be used for "Other specified noninflammatory disorders of cervix uteri", while N88.9 might be used for "Noninflammatory disorder of cervix uteri, unspecified".
If there are abnormal findings on a specimen obtained during the examination, you could consider codes like R89.7 (Abnormal histological findings in specimens from other organs, systems and tissues)

07/25/2025

CPT Modifier 33 – Preventative Services
Used to identify medical care whose primary purpose is delivery of an
evidence-based service, based on recommendations from the US
Preventive Services Task Force.

07/11/2025

Our internet is out. We hope to be back up soon. If your calling the office you won't be able to get through right now. Try again in an hour.

06/23/2025

It's going to be hot this week. Don't forget to drink your water!

06/03/2025

𝗪𝗮𝗻𝘁 𝘁𝗼 𝗵𝗲𝗹𝗽 𝗼𝘁𝗵𝗲𝗿𝘀 𝘂𝗻𝗱𝗲𝗿𝘀𝘁𝗮𝗻𝗱 𝘁𝗵𝗲 𝗿𝗲𝗮𝗹 𝘃𝗮𝗹𝘂𝗲 𝗼𝗳 𝘆𝗼𝘂𝗿 𝘄𝗼𝗿𝗸? AHIMA is partnering with the U.S. Department of Labor to update how the following roles in our field are described in its national occupational database: Health Information Technologists, Medical Registrars, and Medical and Health Services Managers.

📣 We're looking for health information professionals to complete a short questionnaire about your real-world experience.

📧 𝗧𝗼 𝗽𝗮𝗿𝘁𝗶𝗰𝗶𝗽𝗮𝘁𝗲, 𝗰𝗼𝗻𝘁𝗮𝗰𝘁 𝗵𝗼𝗿𝗮𝗻𝗴𝗲@𝗼𝗻𝗲𝘁.𝗿𝘁𝗶.𝗼𝗿𝗴 𝗯𝗲𝗳𝗼𝗿𝗲 𝗝𝘂𝗻𝗲 𝟭𝟯.

To be eligible to participate, you must:
✅ Have at least one year of direct experience in the occupation
✅ Have five or more years combined experience in practice, teaching, training, or supervising
✅ Be currently active in the field and based in the U.S.

A random sample of volunteers will be selected to complete a questionnaire. Those who are selected and participate will receive a $40 VISA gift card and a certificate of appreciation from the U.S. Department of Labor

05/27/2025

Many people assume that if they don’t notice a problem, there isn’t one. But hearing loss often starts so gradually that you don’t realize it’s happening!

📉 Hearing loss can begin in your 20s or 30s. Even if it’s not bothersome until your 50s or 60s, that doesn’t mean it should be ignored.

🎧Why get a baseline hearing test?
✔️ Tracks changes in your hearing over time
✔️ Helps detect early signs of hearing loss
✔️ Allows for preventative measures before hearing loss impacts your daily life

05/21/2025

Coding Clarified Medical Terminology Word of the Day!

Thoracotomy
tho·​ra·​cot·​o·​my
Surgical incision of the chest wall

For a general thoracotomy with exploration, the CPT code is 32100. Other CPT codes related to thoracotomy include those for biopsies, removal of lung tissue, and related procedures.
Elaboration:
CPT code 32100:
This code is used for a thoracotomy (surgical incision into the chest) performed for exploration of the chest cavity.
Biopsy CPT codes:
If a biopsy is performed during the thoracotomy, specific CPT codes would be used depending on the type of biopsy (e.g., lung fluid collection biopsy, lung growth biopsy, lung lining biopsy, etc.).
Removal of lung tissue:
Codes like 32440 (total pneumonectomy), 32480 (lobectomy), and 32482 (bilobectomy) are used for removal of lung tissue.
Related procedures:
Other CPT codes like 32110 (control of traumatic hemorrhage/lung tear repair), 32120 (postoperative complications), and 32140 (cyst removal) may be used depending on the specific procedures performed during the thoracotomy.
Thoracoscopy:
If a thoracoscopy (video-assisted thoracic surgery) is performed, codes like 32601 and 32602 (diagnostic or with biopsy) would be used.
Example:
A patient undergoing a thoracotomy with exploration and a lung biopsy would be coded with 32100 for the thoracotomy and a separate CPT code specific to the lung biopsy (e.g., 32096 for lung fluid collection biopsy).