3D Medical Animation Part 4

HIV cell entry

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HIV cell entry

A Video of Molecules

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This video shows how various molecules look. For example, water consisting of two hydrogen atoms and one oxygen atom.

The others are: glucose, sucrose, amylose, stearic acid, oleic, glycerol, trigglyceride, phospholipid, alenine, serine, leucine, phenyaleine, hexapeptide, peroxide, dioxiribose, thymine, atp, dna, amylpectin and cellulose.

HIV: The Greatest Medical Hoax of our Time. Pt 3

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• "At present there is no recognized standard for establishing the presence or absence of HIV-1 antibody in human blood." (Abbott Lab HIV Test - ElA)
• "The risk of an asymptomatic person with a repeatedly reactive serum developing AIDS or an AIDS-related condition is not known." (Genetic Systems HIV Test - Peptide EIA)
• "The AMPLICOR HIV-1 (PCR "Viral Load") MONITOR test is not intended to be used as a screening test for HIV or as a diagnostic test to confirm the presence of HIV infection" (Roche, Amplicor HIV Test Kit).
• "Do not use this kit as the sole basis of diagnosis of HIV-1 infection." (Epitope, Inc. HIV Test - Western Blot)
• "Clinical studies continue to clarify and refine the interpretation and medical significance of the presence of antibodies to HIV." (Abbott Laboratories HIV Test - ElA)

Wikipedia defines HIV as: Human immunodeficiency virus (HIV) is a retrovirus that causes acquired immunodeficiency syndrome (AIDS) This statement is not only false it is not backed by any scientific proof. HIV does not even classify as a retrovirus by definition since it has never been isolated and it has never been proven that can be spread by any means. Further, in the 100,000+ studies done on AIDS to date there has NEVER been proof that HIV leads to AIDS or that they are even related. In fact, by definition of a retrovirus, HIV may not even exist at all! Yes, you are reading this correctly. The test, we are told, that will tell whether someone is HIV positive and therefore develop AIDS does not even test for the virus itself. It tests for components of the virus antibodies and proteins that we are told are specific only to HIV. This is also FALSE. The first Western Blot test by Robert Gallo tested some 75% of the population as being HIV positive. All he did was lower the sensitivity to target the gay population. He also added hydrocortisone to the list which is found in people who are under stress. There are a number of proteins that are misclassified and all of which can be found in any healthy person in different levels depending on a number of factors. Also, we are told that a T-cell count below 200 is a determining factor for HIV. If you were to take a cross section of the population who do not have any risk for HIV and test their T-cell counts you will find that it ranges from 180-1500. And that is in normal healthy individuals, therefore 200 is at the low end of normal. If HIV were a virus, an infectious disease as we are told it is, it would have spread through the rest of the population certainly by now. Why hasn't it? Because what we are told about HIV and AIDS is a LIE! DEMAND ANSWERS AND QUESTION THE SOURCES! It is unfortunate that we live in a culture in which corporate capitalism is the law of the land. The pharmaceutical industry is calling the shots and they know that they are sitting on an absolute gold mine by spreading disinformation about this and other so, called diseases. Remember, a patient cured, is a customer lost. Follow the money and question those who profit from from it. Robert Gallo is a fraud. His Western Blot Test makes a mockery out of science. His work was NEVER peer reviewed before it was released, and it was later determined that he stole his construct of HIV from French researchers. He has to share the profits from the sales of the so called HIV test as a result. Educate yourself, and be aware of charlatans like Robert Gallow. HIV=AIDS is a LIE. HIV has never been isolated. Robert Gallo is a liar and a fraud. His test for HIV is pure medical malpractice. He should be imprisoned for spreading disinformation and be held accountable for promoting the hysteria he has created over the HIV=AIDS hypothesis.

HIV LIFECYCLE

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For its exhibit at the 2002 International AIDS Conference in Barcelona,GlaxoSmithKline commissioned a three minute film on the life of cycle of the HIV virus,with an emphasis on the mechanism of the integrase molecule in its role in inserting the AIDS virus genome into the host T-cell DNA.

HIV Structure

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HIV structure - overview
HIV structure - viral envelope
HIV structure - viral core

Virus invades cell (bacteriophage T4)

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Virus invades cell (bacteriophage T4)

HIV virus

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Process of HIV virus cell entry

How the HIV virus enters the cell

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hiv e-learning animations

3D Medical Animation Part 3

HIV Replication

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it is a very excellent animation which explains the hiv replication very clearly.

Human Body

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3D Animation of the Human Body

Fantastic graphic interpretation!

Designed in Maya 3D.

Artists were Axel Gaul, Alf Neu, Stefan Gruschke and Fritz Hombach.

HIV Replication and Life Cycle

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HIV replication is a complex multi-staged process that includes crucial steps taking place on the exterior as well as the interior of the target host cell.

The first three steps involved in cell entry are termed attachment, co-receptor binding and fusion. Each step is crucial to successful viral reproduction.

Once HIV virus penetrates the cell, it releases its RNA into the cell.

HIV-Replikation

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Eine Animation der Replikation des HI-Virus

DNA Replication

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DNA Replication

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3D Medical Animation Part 2

Cardio

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Cardio

Animation Inhaler

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A 3D Medical animation of the uses of a Inhaler

Medical illustrations 3d medical virtual simulations MOA

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Medical illustrations and medical animation Tres3d.com 3d virtual medical animations medical illustrations Medical animation studio.com -MOA Method of action videos / mechanism of action video - virtual medical simulations

Pulmonary Embolism

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This 3D animation shows you how Pulmonary Embolism happenss in lungs due to the blood clot formed from the deep veins of leg and raises upward and reaches the heart and then reaches the lungs by lesser circulation or pulmonary circulation.

Dental Implant

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BioDigital Systems created a 3d animation of a dental implant

Virtual point

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Virtual point

Building Blood Flow in Cinema 4D

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A polygonal feast of fury; the accelerated methodology of assembling a blood flow 3D animation in Cinema 4D from primitive objects to final rendering.

Childbirth Stations of Presentation

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This time-lapse 3D medical animation shows the stations of presentation
during labor (labour) and childbirth. The animation follows the baby's
progress through the mother's birth canal, marking the baby's position
by how her head lines up with specific points in the mother's bony
pelvis. These points are called vertex positions, and use the
designations +3, +2, +1, 0, -1, -2 -3 in what obstetricians (OB/GYNs)
call the 1/3 system.

Childbirth Stations of Presentation

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Nucleus Medical Art's 3D medical animation shows the anatomy of a
typical cervical (neck) spine and intervertebral disc. Details include
orientation of the cervical spine, movements of the spinal vertebrae,
and movement of intervertebral discs. A cross-section of the
intervertebral disk and spinal cord highlight the nucleus pulposus,
annulus fibrosus, spinal cord, dura mater, spinal root, and spinal
nerve.

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3D Medical Animation Part 1

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Gal edri - Digital artist - expertise at demonstrations movies

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This 3D medical animation of shoulder dystocia in a newborn shows a vaginal delivery with the uterus removed for greater visibility of the brachial plexus in the neck and shoulder area of the fetus. As the baby is pushed through the mother's pelvic outlet during labor, we see the infant's shoulder being trapped beneath the mother's pelvic bone (pubic symphysis) causing the nerves of the brachial plexus to be stretched and injured. This form of brachial plexus injury is called neuropraxia, and may result in symptoms including a limp or paralyzed arm; lack of muscle control in the arm, hand, or wrist; and lack of feeling or sensation in the arm or hand.

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This 3D medical animation shows how antibodies stop harmful pathogens
from attaching themselves to healthy cells in the blood stream. The
animation begins by showing normal red and white blood cells flowing
through the blood stream. Next, a single pathogen appears onscreen
slowly moving toward its destination on the surface of a cell. The
tubular extensions on the pathogen are surface proteins which attach to
corresponding surface proteins on a white blood cell, or leukocyte. As
the animation continues, more pathogens continue to attach to the white
blood cell, rendering it ineffective.

During the immune system response, Y-shaped antibodies begin attacking
the pathogen, binding to its surface proteins as the pathogen attempts
to anchor to the blood cell. The antibodies completely block the
pathogen from attaching to the blood cell, "tagging" the pathogen so
that one of the immune system's leaner cells, a macrophage, appears
onscreen to engulf and digest the pathogen.

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Nucleus Medical Art's 2007 animation demo reel ... (more)
Added: February 07, 2007
Nucleus Medical Art's 2007 animation demo reel shows surgery, anatomy, mechanism of action (MOA), and physiology produced for medical devices, pharmaceutical companies, biotechnology, marketing agencies, lawyers, and more

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this is a sample from an innovative training system

About this Video

it is a very excellent animation which explains the hiv replication very clearly.

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How to Lose Weight Quickly and Naturally

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There is no hard and fast answer to how much a person should weigh in order to be healthy. But, women need to be concerned about weight because it can and does affect overall health. Obesity, or being overweight, can result in premature death and can contribute to many problems, such as heart disease, high blood pressure, high blood cholesterol, diabetes, cancer, breathing problems, arthritis, and problems with pregnancy, labor and delivery.


The first, and best, thing to do is to talk with your health care provider about your weight. Together, you can talk about what a healthy weight is for you, based on your height, build (bone size, amount of muscle) and age.

You can also use a tool called the Body Mass Index (BMI) to give you a pound range for a healthy weight. You take your weight and height and see where you fall on the BMI table for adults (see below). There is also a handy BMI calculator at the National Heart, Lung and Blood Institute's web site (see resources at the end of this FAQ).

Some general guidelines for losing weight safely are:

• Eat fewer calories. The best formula for losing weight is to decrease the number of calories you get while increasing your physical activity every day. Depending on how active you are, you may need between 1,500 — 2,500 calories a day. A safe plan is to eat 300 to 500 fewer calories a day to lose 1 to 2 pounds a week.

• Lose weight slowly. It is best to aim for losing 1/2 to 2 pounds a week. By improving eating and exercise habits, you will develop a healthier lifestyle. And, this will help you to control your weight over time. You will also lower your chances of getting heart disease, high blood pressure and diabetes. 'Crash' diets may take off pounds faster, but can cause you to gain back even more pounds than you lost after you stop the diet.

• Exercise. Get active for at least 30 minutes every day. You don't have to train for a marathon to be active! Brisk walking, gardening, riding a bicycle, tennis and dancing all count as exercise. You can also break up the 30 minutes into three 10-minute periods. To get even more active every day, you can do things like park farther away from the mall in the parking lot and take the stairs instead of the elevator. The idea is to use up more calories than you eat each day. This will keep the calories from being stored as fat in your body.

• Eat less fat and sugar. This will help lower the number of calories you eat each day. Select foods whose labels say low, light or reduced to describe calories or fat, including milk products and cheese. Eat lean types of meat, poultry, and fish. Eat less sugar and fewer sweets (don't forget that soda and juice can have lots of sugar). Drink less or no alcohol.

• Eat a wide variety of foods, including starches and dairy products. This helps your body to get the nutrients and vitamins it needs to be healthy. Include plenty of vegetables, fruits, grain products and whole grains each day. Don't skip dairy products — there are many good tasting low, no, and reduced fat milks, yogurts, cheeses, ice creams, and other products to choose from. Proper calcium intake is needed for all women to prevent bone loss.

Starch is an important source of energy that all bodies need, even when a person is trying to lose weight. It is found in foods like potatoes, rice, pasta, bread, beans, and some vegetables. Foods high in starch can become high in fat and calories when you eat them in large amounts, or when they are made with rich sauces, oils, or other high-fat toppings like butter, sour cream, or mayonnaise. Stick to starchy foods that are high in fiber, like whole grains, beans, and peas.

• Practice portion control. Eat smaller amounts of food at each meal. Let go of belonging to the 'clean plate club.' Don't feel like you have to eat everything on your plate, even when eating out. You can also try eating more small meals throughout the day, rather than three large meals.

• Get support. It can be hard to start a weight loss program, particularly if you are out of shape and not used to exercising. Ask your family and friends for support. Try to find an exercise buddy. Make your activity fun and social — go on a walk or hike with a friend or learn a new sport like tennis or ice-skating.

• Treat yourself (once in a while). When trying to lose weight, we all feel tempted to 'cheat' by eating a favorite, rich food like cake or cookies. But, sometimes it can be helpful to eat a small amount of a favorite food. This may keep you from craving it and overeating if you do 'cheat.'

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Some Intresting Videos

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In this health video minute on prostate cancer, Dr. Schlegel (Department Chairman) of Cornell Urology discusses the process a patient enters when evaluating the risks of various treatments for prostate cancer including an acceptance of the risks and a balancing of the benefits. In this prostate cancer health video, the focus is on radiation therapy. This approach may allow patients to avoid major prostate cancer operation, but it is not without risk.

Source: An Original HealthTheater.tv Production/In association with the Dept. of Urology, Weill-Cornell New York Presbyterian Hospital. Credits: Executive Producer:Sean Moloney

About this video

Beginning tips on clinical encounters.
Epistemology or how you know what you know or what is the 'truth' is something you need to question throughout your career.

Hands-On Help

This Article provides you with practical tips to help you brush up on your clinical skills. Past columns have covered such topics as epicardial wires, obtaining blood cultures, and drawing blood for ABGs

Hot and cold packs

Applying a heating pad to an arthritic joint or an ice pack to a sprained ankle is a fairly simple approach to reducing pain or inflammation. But even the simplest therapies require an understanding of why you do what you do, and how to do so safely.

Consider the basics of hot and cold therapy. Both relieve pain; they just use different pathways. For each method, the end result is the same: they both block pain impulses and stimulate the release of endorphins.^1,2,3

It's the same for inflammation: different methods, same result.^1,2,3 Cold causes local vasoconstriction and increased blood viscosity. The decreased blood flow and slower metabolism blunt the inflammatory response, limit swelling, reduce oxygen consumption, and control bleeding.^1,2,3

Heat, on the other hand, controls inflammation by causing local vasodilatation and decreased blood viscosity. The increased blood flow quickly brings immune responders to the site and clears away debris. It also increases swelling and oxygen consumption and promotes bleeding.^1,2,3

While these effects are beneficial, there's a downside to both, depending on the size of the area being treated:^4,5 Cold can cause shivering, raise blood pressure, and decrease the respiratory rate. Prolonged exposure may cause blistering or necrosis. Heat can lower blood pressure and increase the respiratory rate. Prolonged exposure can lead to burns and necrosis. Proper management of either therapy is a must.

Things about cold you must know

Cold therapy can be delivered in a variety of ways. Among the most common are disposable ice bags or collars, cold packs, gels, water-filled electric cooling devices, and moist compresses, soaks, or sitz baths.^4,6 In a pinch, you can even use a disposable glove. Fill it with ice and tie up the open end.

Cold works best when applied within the first 24 hours of injury or condition.^6,7 Treatment is usually applied for 15 – 20 minutes followed by at least a 30-minute rest period.^6,7 Because moisture intensifies cooling, cold compresses, soaks, or sitz baths should be used in shorter intervals (10-minute).⁸ Intermittent applications are generally continued for the first 24 – 48 hours.^6,7

What's important to keep in mind is that while some disposable cold packs can be applied directly to the skin, many cannot.⁴ You'll need to wrap cold packs that can't be applied to the skin in a pillowcase, thin towel, or washcloth. The same applies to electric cooling devices that don't have a protective cloth cover. Never place a cooling device on an open wound.⁵

Before you apply cold therapy, always check the order for the type, duration, and number of repeated applications. Assess the patient for adequate circulation and sensation. Gather gloves, waterproof pads, and the cold therapy. Depending upon what's ordered, you may need to bring a clean basin, ice, towels, and tape.

Explain the procedure to the patient, and teach him that some numbness and tingling is to be expected.⁴ But instruct him to immediately report any burning, increase in pain, or severe numbness. These are signs of ischemia, and you should stop the treatment.^4,6

Place a waterproof pad under the area being treated. Don gloves and mold the pack—or wrap the pad—to the injury.

To make it easier to mold the pack to the injury, it's best to fill ice bags, gloves, or collars with small chips, and no more than two-thirds full. Always squeeze the excess air out of the bag, because air interferes with cold conduction.

To make a cold compress, fill a basin with ice and add a little bit of water. Submerge a few hand towels into the basin, so you'll have them ready for subsequent applications. Take out a towel, wring out the excess water, and gently mold the towel around or to the injury. Wrap it in a waterproof pad and tape it down to seal in the cold.

Regardless of the type of cold therapy, check the patient's skin every five minutes or so for signs of cold intolerance, such as pallor, blanching, and mottling.⁴ Keep in mind that edema decreases sensation, so a patient who already has some swelling may not feel any burning or numbness.

When the time is up, remove the device and pat the skin dry. Document the skin's condition at the site, the level of edema, and the patient's response to therapy.

When your patient requires heat therapy

Like cold, there are a variety of devices used to administer heat, including commercial hot packs, gels, wraps, and water-filled heating devices, such as an aquathermia pad (K-pad). In home care, you may also see an electric heating pad or a hot water bottle.^4,6

Never apply a heating device directly to the patient's skin unless the device has a protective cover.^4,5,6 Wrap those that don't have a cover in a thick towel to prevent burning. Heat is transferred more quickly than cold. Never place a heating device under a patient's limb or body part, because compression will promote burning.^4,6

Warm compresses can be placed on open wounds, as long as you use sterile technique.^4,6 While warm sterile compresses are commercially available, you can make one from sterile gauze or towels.

Heat is primarily used to treat the chronic phase of an injury or condition, a time when blood flow is required to speed up healing. (usually 48 hours after an acute injury).^5,6,7 Heat is also used to localize and clear up superficial infections. Therapy is typically applied for 15 – 30 minutes.^6,7

Thermal wraps are an exception. They deliver low heat—104°F (40°C)—and can effectively relieve pain when left in place for up to eight hours.^1,2,9 Thermal wraps restore function in patients who suffer from acute or sub-acute lower back, neck, or wrist pain.^1,2

As with cold therapy, when it's time to apply heat, check the order and gather the necessary supplies. Assess the patient's circulation, sensation, and vital signs. Heat can drop blood pressure faster than cold can raise it, depending on how big the area being treated is.⁴

Explain the procedure, and teach the patient to report any pain or burning sensation. He should also let you know if he feels lightheaded or short of breath. Place a waterproof pad under the area being treated. Don gloves and gently apply the hot pack, compress, wrap, or K-pad to intact skin.

If you need to make a warm compress for an open wound, heat a bag or container of sterile water or saline in a basin of hot water. When it's sufficiently warmed, pour the sterile solution into a sterile basin. Drop sterile gauze or towels into the sterile solution. Don sterile gloves, pick up the gauze, and squeeze out any excess liquid. Check the temperature of the compress by squeezing a few drops onto the inner aspect of your wrist before putting it on the patient. It should feel warm, but not hot.

Pack the compress gently within the wound bed, avoiding the surrounding tissue. Wait a few seconds, assess the patient for pain, then lift up the dressing and check for excess redness, which may indicate a burn. If all is well, cover the compress with dry sterile gauze to prevent infection, and then a towel to seal in the heat.⁴

Warm compresses applied like this need to be changed every five to 10 minutes to maintain the heat unless you apply an aqua K-pad to it.⁴

Assess the skin during all types of heat therapies. The skin should be pink with no increase in edema.⁴ If intense redness or edema occurs, stop therapy and notify the physician of the heat intolerance.

When the time is up, remove the device and pat the skin dry. Note the skin color, wound bed, level of edema, and the patient's response to therapy.

Whether you are applying hot or cold therapy to a patient, vigilant monitoring and documentation are essential. That, combined with your expert application of the therapy itself, will ensure that your patient derives the maximum benefit from what is a very simple therapy.

REFERENCES

1. McCarberg, B., & O'Connor, A. "A new look at heat treatment for pain disorders, part 1." 2004. http://www.ampainsoc.org/pub/bulletin/nov04/inno1.htm (28 Nov. 2006).

2. O'Connor, A., & McCarberg, B. A new look at heat treatment for pain disorders, part 2." 2005. http://www.ampainsoc.org/pub/bulletin/win04/inno1.htm (28 Nov. 2006).

3. Berry, P. H., Covington, E. C., et al. "Pain: Current understanding of assessment, management, and treatments." 2006. http://www.ampainsoc.org/ce/downloads/npc/npc.pdf (24 Nov. 2006).

4. Perry, A. G., & Potter, P. A. (2006). Warm and cold therapy. Clinical nursing skills and techniques (6th ed.), (pp. 1307 – 1328). Mosby: St. Louis.

5. Klein, M. J. "Superficial heat and cold." 2006. http://www.emedicine.com/pmr/topic201.htm (23 Nov. 2006).

6. Perret, D. M., Rim, J., & Cristian, A. (2006). A geriatrician's guide to the use of physical modalities in the treatment of pain and dysfunction. Clin Geriatr Med, 22(2), 331.

7. AHRQ: National Clearinghouse Guidelines. "Clinical practice guideline for the management of postoperative pain." 2006. http://www.guidelines.gov/summary/summary.aspx?doc_id=3284&nbr=002510&string=heat+AND+therap (5 Dec. 2006).

8. Wilson, J. J., & Best, T. M. (2005). Common overuse tendon problems: A review and recommendations for treatment. Am Fam Physician, 72(5), 811.

9. French, D. D., Cameron, M. "Superficial heat or cold for low back pain." 2006. http://www.clinicalevidence.com/ceweb/conditions/msd/1103/1103_I14.jsp#REF12 (5 Dec. 2006).

Patient Information Handouts

Many RN articles include Patient Information Handouts. They're designed for easy reading and cover a variety of topics ranging from bee stings to Alzheimer's disease. Feel free to download these handouts and photocopy them for your patients. There is no need to obtain our permission to reproduce them.

Please note: To view these Patient Information Handouts, you must have Adobe Acrobat Reader installed on your system. If you don't have this program, click on the icon link to the Adobe download page.

How to prevent high blood sugar Body piercing Pain relief Managing chemo's side effects Poison control: Keeping your children safe Fibromyalgia When someone you love has Alzheimer's Insect stings: What you need to know How to stay safe in a lightning storm Preventing heat emergencies Water safety: What you need to know Is the pump right for you? What is respiratory syncytial virus (RSV)? How to care for your burn wound Tips for living with low vision How to keep familiy safe from your staph infection Skin care tips for patients with HIV Living with an implantable cardiac device Preventing surgical site infections

Urology Focus

Interested in urological nursing? Below are articles from the Urology Editions of RN. Articles originally appeared in Urology Times, a sister publication.

Coding Q and A

Follow these steps when appealing a Medicare claim

Q. How do you appeal a denied Medicare claim?

A. If the payer has a standard appeal form, fill out the Medicare appeal form and resubmit it with a copy of the original claims form, Medicare EOB, correct coding edits, and any other supporting documentation that proves the codes should be paid.

If the payer does not have a form, draft a letter stating all the reasons why the claim should be paid according to guidelines and provide proper contact information. In addition, all supporting documentation should be attached.

Certain states have a telephone appeal line where all appeals need to originate. Many Medicare appeal departments have a specific address that all appeals must be processed through.

If the claim is denied by the Medicare appeals department, and the intent is to continue the process of getting the claim paid, state- and payer-specific guidelines must be followed to elevate the appeal to a higher level.

Q. How should I bill when the physician performs a potassium sensitivity test?

A. There is no specific code for the potassium sensitivity test. However, since the test includes the instillation of a drug, then 51700 (bladder irrigation, simple, lavage, and/or instillation) should be used. In addition, you would use the appropriate J code for potassium chloride solution (J3480).

You would also charge an E&M code if there was a significant and separate E&M service provided, for example, a consult or a discussion on the disease process and the treatment of the disease process following the test. Of course, if an E&M visit is charged, the –25 modifier should be attached.

Q. Does code 52352 cover the retrograde pyelogram and ureteral catheter placement?

A. That depends. The CPT book definition for Code 52352 is: "Cystoscopy, with ureteroscopy and/or pyeloscopy; with removal or manipulation of calculus (ureteral catheterization is included)." So, this procedure includes the insertion of a ureteral catheter, insertion of stent, or installation of contrast media if it is used to facilitate the procedure. In this case, all would be covered with the same code.

However, if you were to have scheduled the patient for a diagnostic retrograde, and the diagnostic retrograde led to the diagnosis of the calculus and you proceeded with the 52352, then you should be paid separately for the diagnostic retrograde, 52005.

Unfortunately, it is bundled, and it can never be unbundled. Therefore, you will be denied. However, some payers, upon appeal, will pay, as they appropriately should.

In addition, if the physician inserts an indwelling stent following the procedure, to be left in for removal at a separate setting (52332), then charge 52332 in addition to the 52352. This is bundled, but can be removed with a modifier, and if charged, the –59 modifier should be attached.

This is completely appropriate since the AMA and AUA have determined that an indwelling stent is not a component or an integral part of the ureteroscopy procedure, and if inserted, should be charged separately.

Q. We have confirmed with hospitals that they are billing each component of a urodynamics study (CPTs 51726, 51784, 51795, 51797 and 51741) with modifier TC (technical component). In turn, after one of our physicians interprets the urodynamics results and documents the findings in our patient's medical record, we bill each component with modifier –26. Do you recommend reducing the standard fee for each CPT code billed with modifier –26? Or should we bill full fee for each and let the insurance company determine the reduction?

A. If you have a contract with the insurance company that pays you a set fee for each service performed, such as Medicare, I would continue to bill the full fee for the service and let the payer reduce your fee. However, if this is a patient who's paying his or her own fees, or if this is an insurance company with which you do not have a contract, then you should reduce your fee to the amount that you should expect to be appropriately paid for your services. That would also prevent patients with their own medical savings account from having to pay the full fee out of their pocket. They do not have the edits to monitor the charges; therefore, you should be fair in your charges to those people.

The information in this column is designed to be authoritative, and every effort has been made to ensure its accuracy at the time it was written. However, readers are encouraged to check with their individual carrier or private payers for updates and to confirm that this information conforms to their specific rules.

Answers to your coding questions

Q. How do I charge for a patient sent from a nursing home for a consult who, upon evaluation, required a cystoscopy?

A. For a routine nursing home patient, charge the appropriate level of outpatient consult with a –25 modifier, charge for the cystoscopy (52000), indicate the place of service as "office," and you will be paid as you would for any other office visit.

If the patient is in the first 100 days of discharge from the hospital and Medicare is paying the bill through Medicare Part A to a skilled nursing facility (SNF), E&M services are paid as outpatient services in your office without a problem. However, any "procedure" will be paid as if it were performed in a facility, or a "facility fee." Any service you provide with a technical component and a professional component will only be paid for the professional component. Most important, drugs normally paid by Medicare Part B will not be paid by Medicare Part B when given to SNF patients.

You should have a contract with the nursing home to pay for these services because the SNFs are paid on the diagnosis related group (DRG) concept similar to a hospital. Any unpaid medications, the difference between procedures paid at the facility fee and non-facility fee, and unpaid technical fees should be paid by the nursing facility if you have the appropriate contract.

Q. I work in an office with six physicians. We've set up an operative suite and are considering doing a photoselective vaporization of the prostate (PVP) laser procedure for BPH as an outpatient procedure in the office. We arranged for the anesthesia and all the safety equipment that is required. How do we bill for the procedure, and what will we be paid?

A. I have good news to report. Last year physicians used 52647, which paid both a facility fee for a procedure performed in the hospital in addition to a non-facility fee for a procedure performed in the office or other outpatient setting. A change in the terminology on the laser codes in CPT prevented 52647 from being used to report the PVP procedure as of January 1, 2006. As of this date, therefore, 52648 is the only correct code to use.

The good news came in a recent press release from PVP device maker Laserscope, which stated:

"The correct way to code the laser as an outpatient or inpatient is to use the 52648 in place of service, and the national average payment will be approximately $3,100 for the outpatient procedure and approximately $600 for the procedure if in the hospital."

So, CMS has finally agreed to pay the non-facility fee for the 52648 code as of the beginning of 2006. The new payment rule will apply to all laser treatments of the prostate that are described by that code.

Q. There are a number of different LHRH products now available on the market (both injections and implants). In the case of a Medicare patient who has no preference between an injection and an implant, is there any financial advantage of using one drug over the other?

A. The answer to your question depends on your contract for the drug. There are several issues to consider. First, consider the spread between the cost of the drug and the payment you will receive from Medicare. Obviously, if you're using a three-month drug, that profit will occur four times a year, whereas an implant provides a once-a-year profit.

The other variables to consider are drug administration income, office expenses, and time. E&M visits should not enter into the equation. The Centers for Medicare & Medicaid Services has made it clear that you should only charge for an E&M visit when it is medically necessary. Theoretically, the number of visits should not vary with the injection vs. the implant. The patient should be seen when medically necessary.

Take the injection fee for the drug and subtract the cost for that encounter, and multiply by the number of injections per year. Be sure to compare that profit to the implant fee minus the procedure cost for the yearly implantation.

Another key issue is the physician's time. The doctor usually performs the implantation, whereas a nurse or medical assistant administers the injection. If the injection is chosen, the physician could use that time to see other patients. Once you add these factors together, you'll have your answer.

Q. When doing ultrasound of the prostate alone or with a biopsy in the office, can we bill 76872-26, 76872-TC, and 99215?

A. If the urologist owns the equipment and actually performs the procedure, he or she should charge 76872, diagnostic ultrasound of the prostate, without a modifier. The ultrasound can be charged with or without the prostate biopsy when performed.

If the urologist provides a significant E&M service in addition to the procedure, then a separate charge should be made for the level of E&M service provided. For instance, following a diagnostic ultrasound and the discussion of findings, the urologist discusses the disease process and its treatment. In that situation, an E&M service would be appropriate at the level of service provided.

That level can be reached by either components or time. (Refer to the pocket card and wall chart for details.)

There is no set regulation that would allow the charge of a 99215 with a diagnostic ultrasound. Each E&M service that is provided has to be medically necessary, significant, and separate from the procedure performed, and the reporting must accurately reflect services provided.

Modifier for retrogrades and renal stents * Code 52000 * Billing when the patient's had a transplant

Q. What is the modifier for retrogrades and renal stents placed in the office under fluoroscopy and local anesthesia? What are the codes we should use?

A. First and foremost, for procedures performed in the office, you would use "office" as the place of service, and you would charge the non-facility fee on the fee schedule. For example, the national Medicare average payment for the non-facility fee for the insertion of the stent is $332.74, while the facility fee is $155.

If the physician performs a diagnostic retrograde (52005) and the insertion of a stent (52332) at the same setting, each should be billed separately. No modifier is needed for Medicare because the two are not bundled. However, if you were billing this to a patient with private insurance, I would apply the-51 modifier to the retrograde, which is the lesser of the two procedures. If a physician reads the retrograde in the office and does not send it out to a radiologist for additional reading, then the physician would also charge the radiographic reading: 74420, urography, retrograde, with or without KUB.

Because the physician owns the equipment and is reading the X-ray, charge it without a modifier. Code 74420 without a modifier pays both for the technical (-TC) and the professional fees (-26).

The fluoroscopy, unfortunately, is bundled into the other codes. If the fluoroscopy is used to facilitate the procedure, then it should not be charged.

Charge for the fluoroscopy only if the fluoroscopy is being conducted for a separate reason. For example, if the physician performed a retrograde and the insertion of the stent on the right kidney and he used the fluoroscopy to evaluate the left kidney for stones, then you would charge fluoroscopy and would pull it out of the bundle by using the modifier-LT for the fluoroscopy and-RT for each of the other procedures.

If the patient was originally scheduled for the insertion of the renal stent and the retrograde was performed to facilitate the insertion of the stent, then you would charge only for the stent insertion.

Q. Is the code 52000 listed as a surgical procedure or a scope code?

A. All codes, including the 10000 series of CPT codes through the 60000 series of procedural codes, are considered surgical procedure codes. That includes all of our 50000 series of urologic codes. Within the surgical procedural codes are codes that are considered endoscopy codes. You will find endoscopy codes under the GI, orthopedic, respiratory, cardiovascular, and GU sections. Cystoscopy (52000) is an endoscopy code. In fact, it is considered the base code for many urologic endoscopy procedures.

I recommend that you visit the AUA Coding Today Web site ( http://www.auacodingtoday.com/) and click on "52000." Under the CPT/HCPCS tab, click on the small tab "national," and you will be given a list of codes considered to be in the same family.

In this case, most of the codes are bundled with a cystoscopy, and cystoscopy cannot be charged separately. However, if you bill any of the other two codes in that family, the second procedure will be paid according to the multiple endoscopy rules. The difference between payment for the procedure performed and the base code will be paid, as opposed to the normal procedural reductions, e.g., 50%.

Q. How do you bill for a cystoscopy, laser lithotripsy of bladder stone, and endoscopy of ureteral intestinal segment with removal of multiple stones when the patient has had a transplant, including a segment of small bowel replacing the distal ureter?

A. This situation presents a very interesting problem with coding. First, a 52318-litholapaxy—crushing or fragmentation of calculus by any means in bladder and removal of fragments complicated or large (over 2.5 cm)—was performed and should be charged.

An endoscopy through a stoma from the bladder into the small intestine was performed, which could be partially coded as 44380, ileoscopy, through stoma, diagnostic, with or without collection of specimens by brushings or washings. Unfortunately, there is no comparable code for removing a foreign body through the ileoscopy. I would suggest using 52320, cystoscopy with removal of ureteral calculus, as your second code.

In this case, the stoma is from the small bowel to the bladder and the bowel is functioning as a ureter.

Therefore, I think you are perfectly correct in using the code. As a bonus, 52320 pays a lot better than 44380.

Clinical Tips

Get an error-free sample every time

Scooping up capillary blood (dragging the collection apparatus across the skin to get the blood into the tube) will contaminate the sample, and is a common source of error in point-of-care testing. To circumvent this problem, use an anti-scoop collection device, such as Microvette (Sarstedt, Newton, NC), that can wick up the blood when you gently touch the tube to the droplet.

Sally Beattie, RN, MS, CNS, GNP

Treatment of choice for hyperkalemia

Hold the sodium polystyrene sulfate (Kayexelate)! According to the American Heart Association guidelines, you should treat hyperkalemia first by administering 10 units of regular insulin along with an amp of 50% dextrose. Insulin promotes the movement of potassium from the extracellular space back into the cells, and the dextrose prevents iatrogenic hypoglycemia. Serum potassium levels begin to decline within 30 – 60 minutes with this treatment and remain low for several hours.

Marie Lasater, RN, MSN, CCRN, CNRN

Cancer patients can benefit from massage therap

Massage therapy can help cancer patients by decreasing pain and anxiety, relieving muscle tension, and improving circulation. It can also enhance range of motion, and bolster their immune function. But you should avoid applying deep pressure, particularly near lesions or postoperative sites. Use only gentle, light touch massage on patients with bleeding tendencies. And do not massage patients who have metastatic or thrombotic disease, or those who've undergone lymph node dissection.

Gatlin, C. G., & Schulmeister, L. (2007). When medication is not enough: Nonpharmacologic management of pain. Clin J Onc Nurs, 11(5), 699.

Cassileth, B. R., Deng, G. E., et al. (2007). Complementary therapies and integrative oncology in lung cancer: ACCP evidence-based clinical practice (2nd ed.), Chest, 132(3), 340S.

Gastric lavage is out, erythromycin is in

Erythromycin is a motilin agonist, which means it can effectively speed up gastric emptying. It's now considered a first-line choice for clearing gastric contents in a patient under going esophagogastroduodenoscopy (EGD) for an upper GI bleed. The recommended dose is 250 mg, given as an IV bolus about 20 minutes before the procedure. Gastric lavage may be used if this method fails.

DiMaio, C. J., & Stevens, P. D. (2007). Nonvariceal upper gastrointestinal bleeding. Gastro Endoscopy Clin North Am, 17(2), 253.

Pacifiers help prevent SIDS

The American Academy of Pediatrics recommends using a pacifier to prevent sudden infant death syndrome (SIDS). Encourage parents to offer a pacifier at nap time and bedtime throughout the first year of life. However, if the infant refuses the pacifier, teach parents not to force the issue. Likewise, if the pacifier slips out after the infant falls asleep, it should not be reinserted. Introducing a pacifier can be delayed until breastfeeding is well-established, usually around one month. Pacifiers should be cleaned often and replaced regularly.

Jennifer L. W. Fink, RN, BSN

Latent TB turns deadly if conditions are right

Without treatment, only 10% of those who are infected will develop active tuberculosis (TB). That's because a healthy immune system keeps TB in check. These latent, or non-contagious, cases, however, can become active in patients whose immune system may be compromised by another disease or condition. Think HIV, cancer, diabetes, or prolonged corticosteroid therapy, or substance abuse, for example. Suggest having these patients tested for TB if they show signs such as chills, fever, cough, night sweats, and pleurisy, or have a history of exposure.

Rebecca Ruppert, RN, MS
Salem, OR

Making pediatric injections a little easier

Administering injections or taking blood can be agonizingly difficult if a small child is reluctant to cooperate. A useful way to improve the success rate of pediatric venipuncture is the "magic feather" technique, which uses visual imagery to distract a patient from the painful procedure.

Hand the child an imaginary feather and describe it in detail. Show the child that by blowing gently on the invisible feather, it can be suspended in the air above the child's head. Ask the child to continue blowing to keep the imaginary feather in the air, so its magic power doesn't disappear. When the child is deeply engrossed in playing with the magic feather, venipuncture can be carried out, ideally without the patient even noticing.

Bradshaw, S. E. "Magic feather can aid pediatric venipuncture." http://www.postgradmed.com/pearls.htm (1 Feb. 2007).

Encourage your patients to breastfeed

The American College of Obstetricians and Gynecologists (ACOG) is encouraging healthcare providers to support women who elect to breastfeed their infants. Breastfeeding offers a number of benefits for the mother and infant and is the preferred method of feeding, according to ACOG. Moreover, the group emphasizes that nearly all women are capable of breastfeeding their children. There are only a few contraindications to breastfeeding: use of illegal drugs or high alcohol intake, HIV or certain other infections, and an infant with galactosemia. ACOG continues to recommend exclusive breastfeeding for at least the first six months of life. The group emphasized that education and support for breastfeeding can improve breastfeeding rates for all women and would be a positive economic investment for both health plans and employers because there are lower rates of illness among infants who are breastfed.

The American College of Obstetricians and Gynecologists. "ACOG calls on obgyns, health care professionals, hospitals and employers for increased support for breastfeeding." 2007. http://www.acog.org/from_home/publications/press_releases/nr02-01-07-1.cfm (1 Feb. 2007).

Don't come back to work too soon after the flu

Noroviruses, the culprits responsible for the stomach flu, cause muscle aches, vomiting, diarrhea, and low-grade fever and chills about 24 – 48 hours after exposure. They're highly contagious. For most, the flu is self-limiting. Children often have more vomiting than adults, but it's the elderly who are at risk for a severe case and possibly death. While handwashing is critical to prevention, sick employees should be told to stay home for 72 hours after diarrhea and vomiting stop. Hospitals should also limit visitors.

Rebecca Ruppert, RN, MS
Salem, OR

Hot Careers in Nursing

Nursing career opportunities are greater and more varied than ever before, and the demand for qualified nurses has never been higher. As the health care field becomes increasingly complex and specialized, more and more nurses are finding steady, rewarding careers beyond the traditional hospital setting. If you have a desire to help others, a fascination with cutting-edge medicine or want to explore new places and meet new people, check out five of the hottest careers in nursing.

Travel Nursing Careers

From the pristine beaches of Honolulu to the picturesque coasts of Florida, there are thousands of places in the United States, and around the world, for you to pursue a career in nursing. Travel nursing lets you be in control of your nursing career. You choose the location, specialty and length of commitment for each nursing assignment. With a shortage of qualified nurses in hospitals and clinics across the country, you can find short-term work (typically eight weeks or as long as 26 weeks) in virtually any location and offering generous compensation, often ranging from $22 to $40 per hour. Many facilities also provide perks such as free housing, as well as sign-on and completion bonuses to nurses under contract.


Military Nursing Careers

Support our troops both at home and abroad as a military nurse. In addition to the honor of protecting our nation, choosing a career in the armed forces opens the door to a wide variety of educational, travel and career-enhancing benefits. In return for service in the military, you can receive financial assistance for completing nursing programs, generous financial bonuses, as well as low-cost housing, specialized training and world-wide travel opportunities. Do your part while advancing your nursing career.

Forensic Nursing Careers

Advances in the growing field of forensic science have helped law enforcement agencies bring criminals to justice. From documenting injuries to collecting valuable DNA evidence, as a forensic nurse you will be working on the front lines of justice. You will counsel assault victims, conduct physical examinations and collect evidence. You will also play a direct part in taking criminals off the street by testifying against defendants at trial. As the importance of forensic evidence continues to grow, so will the career opportunities in this exciting new field.

Legal Nurse Consulting Careers

With some specialized training and your RN license, you could be making up to $100 to $150 per hour as a legal nurse consultant. Be a medical detective and use your nursing expertise to analyze complex medical records for your legal team. Apply your medical skills in the courtroom by testifying in court as an expert witness on a wide variety of medical malpractice, product liability and personal injury cases.

Surgical Nursing Careers

As a surgical nurse, you will assist during delicate organ transplants, precision laser incisions and quadruple heart bypasses, to name a few. From preparing patients before surgery to assisting the surgeon in the operating room to charting progress in recovery, surgical nurses are there for patients every step of the way. With a mastery of clinical skills and ability to connect with people, as a surgical nurse you are an advocate for your patient during surgery. Monitoring vitals signs, alleviating discomfort and comforting anxious patients and their families are all a rewarding part of a career in surgical nursing.

Nursing Resume & Job Search Tips

It is broadly agreed upon in the employment sector that the need for Nursing positions will grow faster
than the national job average for the next few years. This is great news for all you interested in Nursing as a career.

Just like in any growing profession there is the inevitable competition for these very desirable nursing positions.

How do you get a head of the competition?

First...Know your stuff. You have to be good at your job. So learn your job well.

Second...Have confidence in yourself, be proud of what you do.

Third...You need an outstanding Resume built specifically for the Nursing Profession.

Remember you are competing for a job in a profession that is growing and you are competing in the
in the age of the email application process. (That means there are hundreds of resumes sent in by
email for each position advertised.)

Once your training is complete and you begin your job search you are stepping out of the world
of medicine and stepping into the world Of "Marketing and Sales".

Your Resume has to have all the important Technical aspects of your training and all the applicable
experience that you also have to offer and every bit of relevant education. But your Resume also has
to stand out from the crowd, and it has to quickly grab the attention of the reader.

Another thing to be aware of, as a result of the volume of resumes generally received for an advertised position, Resumes are not typically read all the way through, they are quickly "scanned".

Did you know that the typical resume is looked at for only about 7 to 8 seconds! Now you see what I mean when I say you have to GRAB the ATTENTION of the READER FAST!

An Outstanding Resume is just as important to your job search as making sure that a patient's Meds are administered correctly o the patients.

Every situation has it's challenges whether you are entry level an RN, BSN, whatever your level of education and experience, there is a need to be thorough and yet maintain a quality of Interest in your resume.

Most hiring managers hire nurses based on their experience or knowledge (education if you are new) in a specific area of the nursing profession. Make this stand out when writing your resume.

While detailing your License Qualifications, grants, academic honors, fellowships, scholarships, GPA, your clinical rotations, or your nursing mentorships is an important thing to do while writing your resume, remember also that your resume format, layout, structure, phrasing, and design are just as important!

In many many cases it is a smart thing to have a professional resume prepared for you. A certified resume writer with experience in the Nursing Field can help you get a better job with higher pay much faster than if you wrote it on your own.

If you go with a professional resume here are a couple of things to look out for:

1: Don't go with a Resume Template. (They don't work)

2. Go with a Professional Certified Resume Writer, experienced in Nursing,
that will guarantee their product. (if it is good it will be guaranteed)

3. Don't skimp on your Resume. This is your career. It is important. Treat it like it is
important and don't go to the $.99 Resume Service. (A cheap resume isn't worth the price.)

Does Team Nursing work? Two Views

The polite term for task allocation

On 11 August 2006, steven222, a Health Care Support Worker, submitted his view of team nursing:

Team nursing is the polite term for task allocation. It completely destroys all lines of accountability and responsibility as no individual nurse has both control of and responsibility for the care of any individual patient.

Team nursing consists of dividing the nursing workforce into two groups and then treating one group (staff nurses ) as too important ever to do any manual labour whilst treating the other group (HCSWs) as too gormless ever to do anything else. Then we go around looking puzzled at the fact that we don't get on! It does however make for a good ideology to justify ignoring the patients call bell if you are a staff nurse.

Team nursing reminds me of the joke about the office where four people called Everybody, Nobody, Somebody and Anybody worked - Everybody thought that Somebody would do it ; Anybody could have done it but in the end Nobody did it. Each job and patient needs one nurse who IS responsible for them not four who might be.

Team nursing also means all HCSWs are permanently confined to basic tasks regardless of their level of knowledge and experience which will ensure that the good ones quit and only the timeservers remain. Team nursing does my head in. We need a national database of all wards which practise patient allocation and which practise bloody team nursing so we know which places to go and work and which to avoid like the plague!

Not a quick fix for understaffed wards

Andrew Heenan wrote this in 2004

There really is no quick and easy answer; there are so many variables; you could just as well argue "nothing works".

A better question would be "How does it work", followed by "(How) can I apply it my area.

Team nursing will not, by itself, improve morale or reduce staff turnover; but it can (applied appropriately in suitable environment) improve nursing care, which can then contribute to staff job satisfaction, then morale, then staff turnover.

If, for example, the nursing home is on two levels, then there is a good case for considering having a team for each level; staff would know where they'd be working each day, thus reducing instantly a major anxiety for some people. If one area is seen as 'harder work' then you could arrange to periodically rotate staff, or adjust staff numbers in each area. Such increased stability would lead to better staff understanding of the need for flexibility in the case of sickness, for example, rather than (for them) a random allocation with no continuity for them or the residents.

'Geographical' division is just one perspective; are there any other ways the resident group naturally divides?

There are other issues, such as skill mix and leadership - could it be practical to have two teams, but one leader (it would need to be a good leader!)

That's just one scenario; it all depends on your local situation.

To me, primary nursing is the ideal, as I believe it offers the patient the best continuity and least potential confusion; team nursing - in practice - has almost always been about stretching resources, not really about improving anything.

In recent years, team nursing has increasingly involved RNs leading a team of untrained staff, whose 'care' the RN is accountable for. This means (of course) that the one person with nursing skills cannot actually use them, because of admin and safety responsibilities. The end of Real Nursing as we know it.

But primary nursing (in my view) cannot work in an under resourced unit, as the primary nurse and the relationship stand to 'take the blame' for the failings of the organization.

Personally, I prefer a 'group nursing' system; smallish teams, with primary nursing within the group - each member being associate nurse for the other nurses' patients. This can reduce the number of individuals involved in each patient's care, and can allow for mentorship and teambuilding within the group.

In fact, I don't know of any system that is safe when nursing is under resourced - but while nursing models have had their reputation blackened by a plethora of time wasting jargon-ridden twaddle based on poorly researched undergraduate course work, promoting independence and involving significant others remains a "least worst" option.

When planning a system of nursing, there is never - ever - a 'quick fix'.

Team Nursing CAN Work:

Ari Haytin, Student Nurse, UCSF, Submitted this 7th April 2007:

I would like to respond to the article that took the perspective that team nursing was more detrimental than beneficial. First the author believed that team nursing “destroys all lines of accountability and responsibility.” This can be the case if the unit is not a well-organized team. There are teams that people are enthusiastic and committed to being a part of and others where the morale is low and the members are not satisfied to be there.

The author’s experience of team nursing has been one of hierarchy and division, which is one way of organization, but it is important to be aware that there are other ways to organize teams. I am currently a nursing student that came from a counseling position in a community oriented public health clinic and never planned on working in a hospital partly due to the organization of many hospital units that lack a true team environment.

When I say true team environment I mean one that values all of the players on the team, that gives them all a voice and opportunities to grow and expand in their position. I have had the opportunity to observe many different units and truthfully to my surprise found that there are some units in the hospital that have amazingly well-organized teams. My first day observing at the Emergency Department the MD’s introduced themselves to me and welcomed me. The staff gave each other a lot of respect, trust and were there to assist one another when they needed it. I think this organization especially common in ICU and ED departments that have a high rate of success with their patients’ outcomes. I hope that some of the teams with low morale would look for ways of reorganizing their team instead of giving up on the team.