Clinical Lecturer/Subspeciality Trainee in Maternal and Fetal
Medicine, Maternal and Fetal Health Research Centre, St Mary?
Hospital, Manchester
Another American dentist erectile dysfunction caused by spinal stenosis generic malegra fxt 140 mg overnight delivery, Horace W ells what causes erectile dysfunction cure buy malegra fxt 140 mg on line, thought of using nitrous oxide for extractions erectile dysfunction in diabetes ayurvedic view buy 140 mg malegra fxt fast delivery, and he had one of his own teeth painlessly pulled in D ecem ber 1844 erectile dysfunction treatments vacuum purchase 140mg malegra fxt with amex, proclaiming a new era o f tooth-pulling erectile dysfunction at the age of 20 order malegra fxt 140 mg on-line. Medical scepticism about his claims was to lead W ells to com m it suicide shortly after impotent rage quotes malegra fxt 140mg. Anaesthesia gained approval although ether was soon challenged by the safer chloroform. On 19 Ja n uary 1847, Jam es Young Simpson o f Edinburgh used chloroform for the first time to relieve the pains of childbirth, and it soon began to be used extensively for this purpose, even for Queen Victoria (see page 263). Acceptance o f anaesthesia made more protracted surgery feasible, but it did not by itself revolutionize surgery, however, because o f the severe death rate from postoperative infection. W orking in 1848 in the first obstetrical clin ic of the Vienna general hospital, Ignaz Semmelweis remonstrated against the dreadful fatality levels from puerperal fever. He observed that the first clinic (run by m edical m en) had a m uch higher rate of puerperal fever than the second obstetrical clinic, run by midwives. He became convinced that this was caused by medical staff and students going directly from the post mortem to the delivery room s, thereby spreading infection. He instituted 230 The C ambridge Illustrated H istory of M edicine a strict policy of washing hands and instrum ents in chlo rinated lime solution between autopsy work and han dling patients, and the m ortality rate in the first clinic was diminished to the same level as the second. Antagonism to Semmelweis was not mere professional closing o f ranks but was consistent with the aetiological theories o f the time. The leading view was that infections were caused n ot by contact but by miasmata in the air, em anations given off by non-hum an sources. Adherents of such views therefore gave priority to ventilation and prevention o f overcrowding as preventive measures. Alcohol gained favour, and around 1820 iodine becam e popular in France for treating wounds. Other substances used as antiseptics included creosote, ferric the leading American painter of medicine in the late nine teenth century was Thomas Eakins. Samuel Gross, distinguished professor of surgery at Jefferson University Medical College in Philadelphia, dem onstrates an operation for osteom ylitis, a serious hone infection. The patient is receiving an anaes thetic (eth er), hut the sur geons w ear street clothes, without masks and gloves, and the unsterile surgical equipment lies exposed in an instrum ent case. Almost a decade after Joseph Lister developed his antiseptic pro cedures, Gross is still not using carbolic acid to prevent wound infection. There was thus some interest in questions of antisepsis before the labours of Joseph Lister. It was, nevertheless, Lister who introduced effective techniques for antisepsis and who proved a vocal and effec tive propagandist on their behalf. The carbolic spray, which saturated all concerned and was heartily disliked, came under criticism and Lister him self abandoned it. As early as 1874 Louis Pasteur had suggested placing the instruments in boiling water and passing them through a flame; heat sterilization of instrum ents was accepted by Robert Koch in 1881. By 1900, these and other prophylactic antiseptic and aseptic methods had been put into use by all surgeons. No longer did surgeons operate in blood-caked black frock-coats in dingy rooms with sawdust-covered floors. The introduction of face-masks, rubber gloves, and surgical gowns lessened the risks of infection, and clean and sterile environm ents were constantly being improved. As late as 1874, Sir Jo h n Erichsen believed that the abdomen, chest, and brain would forever be closed to operations by wise and hum ane surgeons; and Lister rarely probed into m ajor cavities, mainly setting fractures. Wound infection and putrefaction in wounds had long been accepted as the almost inevitable consequence o f exposure to the air. Lister came to the conclusion tha t car bolic acid would be effective as an antiseptic, a judgm ent reached after considering its influence in reducing cattle disease and its successful use to combat a typhoid epidemic in Carlisle, Cumberland. Lister undertook his first trial on 12 August 1865 on an 11-year old boy, James Greenlees, whose le ft leg had been run over by a cart, dressing a compound fracture o f the tibia with lin t soaked in linseed oil and car bolic (creosote). He kept the dressing in place 4 days, cover ing it with tin fo il to prevent evaporation. The carbolic treatm ent was again applied and the wound healed with ou t infection. Lister was not a profound theo retician, but he was an expert practi cal and surgeon, the insisting he on basic precautions such as hand-washing, technique invented Joseph L ister (left), one of the true heroes of nineteenth-century medicine. His careful trials with antiseptics were the beginning of the end of postoperative sepsis. The carbolic sprays he advocated (show n in this 1882 engraving) were at first, however, m essy and unpleasant. Blood was expelled from the wound, which was bathed with carbolic; car bolic-soaked lin t was applied to it and a covering o f tin foil was taped over the dressing; when a new dressing was required, the tin was lifted and fresh carbolic painted on the lint. But all was not plain sailing, partly because surgeons hated the smell o f the car bolic (which could also seriously irritate the skin). Lister also long experienced opposition in Britain, other surgeons claiming sim ilar success rates with ou t using his beloved carbolic sprays. First in Zurich and then in Vienna, the celebrated Theodor Billroth made im portant innovations, perform ing the first total removal o f a cancerous lar ynx, pioneering abdominal surgery, and developing surgery for many forms of cancer, especially of the breast. Removal of gallstones grew com m on, and cholecystectomy, the removal of the gall bladder itself, was introduced in 1882. Surgery on the small intestine, notably for cancer, was also inaugurated around the same time, and urological surgery devel oped, especially prostate operations. By 1900 a marked change had occurred in the num ber and type of operations surgeons were executing. For so long an emergency treatment or a last resort, operative surgery had becom e a powerful, even a fashionable, weapon. A surgical revolution had already been wrought by the time of the First W orld War: conditions such as gastric ulcers becam e routine targets for the knife. A German, Ernst Ferdinand Sauerbruch, led the field in thoracic surgery, although it was an Italian, Carlo Forlanini, who introduced pneum othorax treatment. Two surgeons were even honoured at this time with a Nobel Prize - Theodor Kocher in 1909 for his work on the thyroid gland, and Alexis Carrel in 1911 for his tech niques of suturing blood vessels and work on transplantation and tissue culture. A professor at Berne from 1871, Kocher developed general surgical treatment of disorders of the thyroid gland, including goitre and thyroid tumours, and elu cidated the workings o f the thyroid gland. From the 1870s investigations had shown that the thyroid was essential to life; its m alfunction was blamed for cre tinism, goitre, and various other disorders. As a consequence, enlarged thyroid glands began to be surgically removed - som etim es with disastrous consequences if the thyroid tissue left behind performed inadequately. It was shown that this could be prevented by counterbalancing injections of macerated thyroid tissue. Since delayed growth and slow learning were am ongst the features of cretinism, thousands of underachieving children were placed on thyroid extract, and it was recommended for sundry symptoms in adults from constipation and obesity to tiredness and depression. Ho spitals and Surgery 233 In a similar way, testicular extract also becam e popular. On 1 Ju n e 1889, Charles-Edouard Brown-Sequard reported to a distinguished scientific society in Paris that he had rejuvenated him self through subcutaneous injections o f extracts of guinea-pig and dog testicles. For his part, Alexis Carrel, a Frenchm an from Lyons, was involved in many aspects of surgery on the blood vessels and heart, and in particular in treating aneurysm. A constellation of advances - far too many to list - followed from the crucial interlinking of patho logical anatomy, anaesthesia, and asepsis. From the latter decades of the n in e teenth century, surgeons directed their attention to tum ours and infections leading to obstruction or stenosis (constriction of vessels), above all in the diges tive, respiratory, and urogenital tracts. The habitual perform ance o f operations on the gastrointestinal tract, thyroid, breasts, bones, and blood vessels made surgery safer and more reli able. Abdominal surgery advanced with new m ethods of extirpation of cancer of the rectum, of hernias, and with treatm ents for acute appendicitis and disorders of the colon. The first specialist in neurosurgery was Harvey Cushing, who becam e professor of surgery at Harvard University in 1912. Some surgeons became positively cavalier: the Irish-born W illiam Arbuthnot Lane advocated the removal o f yards o f the gut for ordinary constipation - or even as a prophylactic measure. Between 1920 and 1950 hundreds of thousands o f tonsillectom ies were performed, m ost quite unneces sary. Surgical intervention was stimulated by many developments within medicine, bu t it was also demanded by events in the wider world. With war wounds occurring on hitherto unimaginable scales, debates raged once more over proper methods of wound management. Experi ence in the two world wars led to new methods of handling compound fractures; to the development o f plastic and reconstructive surgery; and to the establishm ent of blood and plasma banks (the first were set up in 1935 at the Mayo Clinic in Rochester, New York State). In 1 938, during the Spanish Civil War, techniques were developed of administering stored blood by indirect transfusion into the patient from a bottle; these were perfected in the Second World War. Blood trans fusions, first pioneered in the seventeenth century, had finally been made safe. By 1950, better im m unological knowledge and the increased availability of Opposite: By the late nine teenth century, surgery had made real advances. In this 1 8 9 0 painting by Adelbert Seligmann of the great German surgeon Theodor Billroth at w ork in the Allegemeines Krankenhaus in Vienna, the patient has been anaethethesized and the doc tors are wearing white coats over their suits. Yet m uch still seem s highly traditional, not least the total absence of any thing resembling the m odern operating theatre, and the dependence on daylight. Moreover, nobody is wearing gloves or masks, and it is questionable if the instru ments were properly steril ized. Germ an-born, Billroth became director of the Second Surgical Clinic in Vienna, pio neering surgery for gastroin testinal conditions and vari ous cancers. Thanks to antibiotics, surgery could be performed on cases hitherto deemed too risky because of danger o f infection; for example, interventions in the lung in contact with atm ospheric m icroorganisms. With the pharm acological revolution, such patients could be treated before and after the operation with sulphonamides and later antibiotics. Surgery entered a new phase, moving from a preoccupation with removal to a subtler concern with restoration. Surgeons developed a growing capacity to con trol and re-establish the functioning of the heart, lungs, and kidneys, and fluid balance. The first im plantation of an artificial apparatus (prothesis) came in 1959 with the heart pacemaker, designed to adjust beat frequency by means of electri cal impulses in the case of arrhythm ic variations. Such restorative procedures now range from eye lenses to pneum atic im plants to facilitate penile erection. A fine instance of the sw itch of surgical approach from excision to implanta tion is offeredjby changes in urology. This was challenged by radiotherapy as an alternative proce dure: in 1906, an American, Alfred L. Gray, introduced radiotherapy for carci noma of the bladder, and this was soon used also in the therapy of prostate cancer. Bladder cancer was then one of the first to be successfully treated with hormones (1 9 4 1), thanks to the work o f Charles Brenton Huggins, a Canadian-born Ameri can surgeon who undertook investigation o f the physiology and biochem istry of the prostate gland. Research on dogs led Huggins to the possibility of using hor m ones in treating such tumours in hum an beings and in 1966 he shared the Nobel Prize for his discovery of horm onal treatm ent for prostate cancer. Improvements in heart surgery began with the first operation for stenosis of the mitral valve - the abnorm al narrowing of the valve between the left auricle and ventricle, w hich slows down the blood circulation and eventually causes harm. This was performed by Henry Souttar in London in 1925, and was followed in 1947 by operations to relieve pulmonary stenosis (narrowing of the opening between the pulmonary artery and the right ventricle) by Thomas Holmes Sellors and Russell Brock, also in London. Two years later similar operations were under taken for stenosis of the aorta itself. In 1942, it was suggested that congenital heart disease (the so-called blue-baby syndrome) could be cured surgically. The operation, first undertaken at Joh n s Hopkins Hospital in Baltimore in 1944 (see page 8), launched modern cardiac surgery. The pioneer was Helen Brooke Taussig, an American paediatrician who was the first woman to becom e a full professor at Jo h n s Hopkins University. Taus sig worked on congenital heart disease in association with the cardiac surgeon Alfred Blalock. The babies were blue because o f congenital anomalies that caused blood to pass directly from the right cham ber of the heart to the left w ithout being oxygenated in the lungs; this was then surgically rectified. Their jo in t efforts helped create a new speciality of paediatric cardiac surgery. Operations on the mitral valves increased, but in some cases they initially pro duced severe brain damage by depriving the brain o f oxygen. The idea was then floated o f entirely removing the heart from the body, and deploying an alternative system of blood circulation. It was developed by an American public health engineer, Philip Drinker, in the 19 3 0 s. One was the use of hypotherm ia, reducing through cold the oxygen need of the tissues. Another was the building of the heart-lung machine, maintaining artificial circulation through the great vessels while the heart was bypassed and the operation performed. Through experi ence it was discovered that the deeply cooled and bypassed heart could be stopped for up to an hour and started again w ithout suffering damage. Successful skin grafts were described by the Swiss, Jacqu es Reverdin, as early as 1869. Such autografts (tissue transplantations within the same patient) were soon used to treat ulcers and burns. Skin grafting led to the rise of reconstructive surgery, first 238 The C ambridge Illustrated H istory of M edicine through the work of Harold Gillies on First W orld W ar casualties at Aldershot in southern England. The rise of organ transplantation brought inescapable ethical and legal predica m ents for medicine. Under what circum stances m ight living hum an beings ethi cally becom e donors o f kidneys and other organs? Were the dead autom atically to be assumed to have consented to the removal o f organs?
His tongue bled profusely from the first blow and the convulsive clenching of his jaw how to fix erectile dysfunction causes cheap malegra fxt 140mg on line, chewing his tongue between the back molars erectile dysfunction doctor lexington ky discount malegra fxt 140mg on line. The seizure ended impotence mayo malegra fxt 140mg visa, and the emergency physician impotence with beta blockers 140 mg malegra fxt free shipping, recognizing the seriousness of the situation impotence losartan purchase 140mg malegra fxt fast delivery, immediately transferred Harvey Gold- the Rape of Emergency Medicine Page 297 man to the Massachusetts General Hospital erectile dysfunction from nerve damage buy 140 mg malegra fxt. He had an organ donation card in his wallet, but his brain was flattened, his kidneys laced with pus, his liver filled with microabscesses, and his adrenals had literally collapsed from the weight of the fulminate infection. The fact that he often used Monk to work for him would come out in court, and that would do Harvey no good. He was tired, and longingly wanted to return to the life of meetings in cities like New Orleans, telling anecdotal humorous stories, speaking proverbs from Satchel Paige and Yogi Berra, exhorting emergency physicians to fight the big bad forces of government, and demanding short-sighted hospital administrators approve transcribing fees for effective chart wars. He wanted to hear the young residents wildly applaud him, and he wanted his reputation back, the one of the combination Mark Twain-Norman Rockwell dean of emergency medicine, the one he had so brilliantly and deceptively cultivated while the "scrubs" did all the heavy lifting. They were so young and stupid, genetically too weak-willed and the Rape of Emergency Medicine Page 298 defective in moral character to even pick up the phone and call a hospital themselves. Besides they needed him, as several insurance companies began to question his high, six-figure income. The government was also launching an investigation into shadowy group practices, and already an indicted hospital administrator in Des Moines was plea bargaining embezzlement charges, offering to testify on bribes against one of the Kansas-based "management" groups. The public needed Goldman to set things straight, the American Academy needed him, and now more than ever, Monk needed him. I now have two small children, and am quite concerned there are no controls over emergency medicine other than the avarice of the bloods, crips, and weasels. These physicians turned, as the American Acad- the Rape of Emergency Medicine Page 299 emy calls them, "entrepreneurs, " appear to be without any sense of decency, even within their own community? Ask first if the emergency department is centrally managed by an absentee landlord. Find out how much money leaves the local community for these "management" services. Has only the director remained stable while the "scrubs" have "burned out" at an alarming rate? Find out, particularly, if any fine "scrubs" were picked up by other democratically-run local hospitals and kept there. The Rape of Emergency Medicine Page 300 Chapter Twenty-Four: A Modest Proposal "No lie can live forever. Mahoney felt a certain camaraderie with Delorenzo since they were in the same residency program, having worked many nights together with the adrenalin flowing. He was writing the Model Emergency Medicine Contract for both hospitals and physicians. It was just like him, physician, humanist, and many times a torchbearer, to put together the formulation of fairness with no bullshit. And a national registry will be set up of all multistate, multiple intrastate, and individual emergency medicine "management" corpora- the Rape of Emergency Medicine Page 301 tions. The registry will contain the names, addresses, and phone numbers of any hospitals which in the past did not renew their contract with the "management" group, regardless of the stated reasons. This list needs to be submitted to the state health department of every state in which the group wishes to do business, even if it simply mails glossies to the hospital administrators. By law, this list will also be submitted to every hospital administrator with which the group wished to do business, fully apprising them of their past records, and this comprehensive list on non-renewed contracts has to go back to the inception of the groups, regardless of how many birthname changes, takeovers, buyouts, mergers or acquisitions its undergone. Stiff fines and prison terms will accompany any omissions or "oversights" on the list. Immunity statutes would apply to all hospital administrators regarding libel and slander laws. Administrators would actually be encouraged to say exactly why they dropped the contract with any crip, blood, or weasel with which they chose not to continue. A formula would be devised allocating hard costs like malpractice and billings, and then a specific amount would be allowed for management fees. This would insure that the physician the Rape of Emergency Medicine Page 302 seeing a complicated case would receive the bulk of the fee or share the fee amongst a group of democratically-organized emergency physicians according to the Model Emergency Medicine Contract. I would propose using the input from as many "scrubs" around the nation as we can. The collapse of their empires will be the greatest thing for the specialty of emergency medicine since the accreditation board was approved. You see, Phil, the way emergency medicine has existed would be analogous to saying Yellowstone is a national park, but there will be no regulations. We all know pretty soon the Snake River would be fished out and following that, the osprey and eagles would die off. Poachers would eliminate the elk herds in a matter of a few years, and timber companies would eliminate the danger of forest fires forever. This is the way the landscape of emergency medicine has been pillaged over the last two decades, and the reason is the nonexistent set of rules. I now agree with you and Abe Steinerman that the lack of regulation has spawned this perverse situation existing today which creates entry barriers to new physicians. The American Academy will obviously fight tooth and nail against a mandatory, model contract for both hospitals and physicians, and will insist upon putting another coat of paint on the outhouse, giving a stripped-down version of lip-service reform, providing giants loopholes for the "suits. Mahoney was feeling a certain surge of elation and pride as well as a little guilt. We need to eliminate the noncompete clauses, and holster the legal firepower of the "suits. We now have to stem the exodus of some of the best and brightest in our specialty. It is clearly a de facto restraint of trade to force the emergency physician to work for the same "management" group in the same area for the rest of time. After two years, retroactive from the passage of the bill, a group of physicians can elect whether to self-manage, contract with another group, or stay with the same group. This will rattle the future fortunes of the "suits, " but it will require a grass roots movement of "scrubs" and consumers to pass. Remember, Phil, our teachers gave us a gift, a gift that cannot be silenced, even by the weight of the present leadership pf the American Academy of Emergency Physicians. We need to put the harsh spotlight on this entire field ourselves with a new organization. We need to inform Democrats and Republicans alike of the On the Waterfront maneuverings and injustices, the sheer gangsterism that has so conventionally evolved under the auspices of the "Founders" and the Academy of Emergency Physicians. They, not the American Academy, who feels this is a perfect formulation, can decide the fee distribution. Corollary one: Multi-licensed incompetent physicians are equally incompetent in all states in which they work. The competence of physicians working in an emergency department is inversely proportional to the number of promotional "products" and "services" merchandised by the emergency medicine "management" group. The crips and the bloods with the most extensive "quality assurance" programs assure the lowest-quality physicians. The more money and time a "suit" spends on risk management, the more he increases the risk. Taking a sick child to a non-owner-occupied "doc in the box" is a form of child abuse. Must Document: o > 50% of facetoface time was spent providing "Counseling or Coordination of Care". In practice, criteria for these codes may be met by documenting only 2 of 3 of the key components at or above the level required by the code. Patient doing well until 2 days ago (timing) when, for no apparent reason (context), he refused to leave his bed and appeared extremely (severity) and continuously depressed (quality); he is sleeping more and eating little (associated signs and symptoms). The patient reports doing well until 1 week ago (duration) when he stayed up all night to finish a term paper (context). He has slept poorly (severity) since (timing) and, 2 days ago, began hearing fairly continuous voices (quality) telling him that people plan to shoot him. High probability of A or B recurring if patient were to be discharged, and imminent re-hospitalization likely. Recovery depends on use of modality, but patient unwilling or unable to cooperate. Has a general medical condition (other than mental disorder) requiring hospital care and due to psychological aspects, patient cannot be managed as well on non-psychiatric unit. History of Present Illness: Elements: Location, Quality, Severity, Duration, Timing, Context, Modifying Factors, & Associated Signs and Symptoms. If unable to gather from client or others, indicate and describe condition preventing collection. Past Medical Hx: Check if no change (or updates below) and see note dated / / for detail. Diagnoses: Medications: Surgeries: Allergies: Family History: Check if no change (or updates below) and see note dated / / for detail. Social History: Check if no change (or updates below) and see note dated / / for detail. Systems: Document Notes if Positive: Check if no change (or see changes indicated below) and see note dated / / for detail 1. Vital Signs (any 3 or more of the 7 listed in this box): Blood Pressure: (Sitting/Standing) (Supine) Height Weight Temp Pulse (Rate/Regularity) Respiration General Appearance and Manner (E. May we bill for both a 32390791 Psychiatric Diagnostic Evaluation and a 56590792 Psychiatric Diagnostic Evaluation with a Medical Component on the same day by different providers? May we bill either 32390791 or 565 90792 twice in the same day by the same provider? A: Yes, but only if different "informants" (such as client and family member) are seen in each Psychiatric Diagnostic Evaluation. Also, be sure to indicate "telephone" in the "location" field so that only MediCal is billed. A: Do we use code 32390791 (Psychiatric Diagnostic Evaluation) when we complete the Community Functioning Evaluation? One advantage to this code is that all disciplines (with appropriate training and experience) may gather the Community Functioning Evaluation (or approved equivalent form) data. Q: Now, that Medicare requires that the choice of many billing codes (those with time frames, minmax) be done on the basis of facetoface time, can we bill for work done exclusively on the phone. A: Yes, the choice of the code would then be based on the client contact time and you would select the location code "telephone". However, if there is another appropriate code (that the service meets) you may claim and chart to that service. Q: the Crisis Intervention code has been eliminated and replaced with Crisis Therapy (37790839, 378+90840). A: Yes, the definition of Crisis Intervention Services has not changed-only the Code Label. With the appropriate training and experience your staff may provide Crisis Intervention Services-now identified as Crisis Therapy. We now see code 41390846 ("Family Psychotherapy without Patient Present") and code 449 90847 ("Family Psychotherapy with Patient Present") on the Master Code List. Q: the Interactive Complexity addon code 491+90785 is used for 45690853 Group Psychotherapy. Can it also be used for 45590849 MultiFamily Group Psychotherapy and/or 391 Group Rehabilitation services? A: No, the only group related code that the addon code 491+90785 Interactive Complexity may be used with is code 40690853 Group Psychotherapy. Q: the Interactive Complexity addon code 491+90785 is used for Individual Psychotherapy. A: No, Interactive Complexity addon code may not be used for Family Psychotherapy; however it may be used with Psychiatric Diagnostic Evaluation (32390791, 56590792), Group Psychotherapy (45690853), Individual Psychotherapy (44190832, 44290834, 44390837), and the Individual Psychotherapy addon codes (465+90833, 467+90836, 468+90838). A: No, 491+90785 Interactive Complexity addon code may only be used in conjunction with a Primary E/M code which also has a Psychotherapy addon code (465+90833, 467+90836, 468+90838) associated with it. Q: May we bill the Psychiatric Diagnostic Evaluation codes 32390791, or 56590792 without the client present? If you interview the client on the phone-note that as the location code and you may bill these codes. A: For InSyst, select the 491+90785 code and enter one (1) minute for the duration of service as a placeholder. However, when entering data into the database you total all of the ff time beyond the first 60 minutes and enter those minutes in the "second ff minutes" field for the addon code. Q: May we use the Psychiatric Diagnostic Evaluation codes 32390791, or 56590792, for reassessment purposes? Q: If we provide an E/M service in the field, at school or at a home may we use the E/M codes 9921199215 which indicate "Office or other outpatient visit"? A: Yes, also select the appropriate "Location Code" when utilizing these E/M codes. A: Yes, if each provider writes a separate note and indicates what unique contribution each had, or why a second person was needed. May we claim Interactive Complexity when we have an Interpreter present to overcome the language barriers to therapeutic interventions? May we claim Interactive Complexity when we utilize play therapy equipment for the majority of the session (sand tray, etc. A: Yes, the use of play equipment throughout the session allows you to claim for Interactive Complexity. However, you may claim for your time for transportation and documentation time as below. If you have needed to choose Crisis Therapy or Psychotherapy addon codes- add the documentation and travel time to the minutes for the last addon code (but do not add an additional addon code for those minutes). In the "Primary Clinician Time" field, add the ff time with the documentation and travel time and enter the Total Time.
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