Thomas O. Staiger

Understanding Center for Medicare and Medicaid Services (CMS) documentation and coding rules is challenging for most physicians. To accurately bill for clinical services, physicians must learn a system that may initially seem daunting, but is in fact governed by a small number of straightforward rules. The Evaluation and Management (E/M) guidelines for all service codes specify 3 components: history, examination, and medical decision-making, each with a defined set of elements or characteristics. Service coding is based on the level of care supported by the number of history and examination elements and the complexity of decision-making. This article will clarify the guidelines for outpatient clinical services and suggest a practical method of selecting appropriate E/M codes. Because physicians must often choose between billing codes 99213 and 99214 for a visit by an established patient, it will particularly focus on the minimum documentation needed to bill a 99214 code.

OBJECTIVE: To determine whether a patient-physician agreement instrument predicts important health outcomes.

Three previous reviews have reached conflicting conclusions regarding the efficacy of antidepressants for patients with back pain. To systematically review the efficacy of antidepressants for the treatment of patients with back pain and to determine whether there is evidence that outcomes vary between classes of antidepressants. Best evidence synthesis of randomized, placebo-controlled trials of oral antidepressive agents in patients with back pain. Studies were identified by searching MEDLINE, PsycINFO, and the Cochrane Controlled Trials Registry. Two independent reviewers performed data extraction and assessed included studies with a 22-point methodologic quality assessment scale. Effect sizes were calculated if sufficient data were available. Twenty-two trials of antidepressants for the treatment of back pain were identified, of which seven studies of chronic low back pain met inclusion criteria. Among studies using antidepressants that inhibit norepinephrine reuptake (tricyclic or tetracyclic antidepressants), four of five found significant improvement in at least one relevant outcome measure. Assessment of these agents' impact on functional measures produced mixed results. No benefit in pain relief or functional status was found in three studies of antidepressants that do not inhibit norepinephrine reuptake. Based on a small number of studies, tricyclic and tetracyclic antidepressants appear to produce moderate symptom reductions for patients with chronic low back pain. This benefit appears to be independent of depression status. SSRIs do not appear to be beneficial for patients with chronic low back pain. There is conflicting evidence whether antidepressants improve functional status of patients with chronic low back pain.

PREVIEWAcute low back pain is generally a self-limited condition, and most patients recover within a few weeks without the need for imaging studies. However, physicians need to be on the lookout for red flags that point to more serious conditions, such as infection or malignancy, which require imaging. In this article, the authors identify these warning signs and discuss the appropriate use of imaging studies for a variety of symptoms and conditions.