Patient calls in for a prescription

[TWR]

I was wondering given the following scenario, established patient calls in for a "Z Pak" (example), she's been sick for 4-5 days with standard URI symptoms and has done most of the otc stuff.  Occasional low grade temp (99-100) on and off.  After your conversation, you agree to escribe or call in the "Z Pak" and you document the conversation.  My question is can you bill the patient  for the "conversation" time?

[JPMiller]

Why are you prescribing abx for a cold?

[jmj11]

Regarding your original question, CMS (Medicare) has established codes for phone calls. However, like so many of interventions, if you bill for it, as we have, they usually deny payment.  See http://www.priorityhealth.com/provider/manual/billing-and-payment/services/phone-and-e-visits. 

[LKPAC]

I don't prescribe over the phone. I consider this dangerous in too many cases.  It's also lazy medicine IMHO.  I see a patient, talk and listen to them, perform a proper exam, and make a diagnosis.  THEN I decide a proper treatment plan and explain it to the patient.  

[Reality Check 2]

Not so much about billing as it is appropriate medicine.

 

The joke around my office - "it must be viral, give him a zpak".......

 

I believe it is more appropriate to evaluate the patient and prescribe on site and according to findings - not by phone assessment.

 

My exception might be the O2 dependent COPD pt with hx of mycobacterium avi

[rev ronin]

I will only ever rx abx without patient in front of me if I've seen them in the last 3-4 days and they agreed to deferred rx.  If it's bad enough to get an antibiotic, it's pneumonia needing hospitalization until proven otherwise on exam.

[BruceBanner]

We Rx over the phone fairly often here for established patients....but only for things like flagrant UTI's, siblings with conjunctivitis, etc. Almost never for a cold.

 

But to answer your question, no, I dont believe you can bill for phone time. There might be a way, but I've never done it.

 

And re: the abx thing....if they are sick they need to be seen. Period. We cant be the Domino's of antibiotics anytime someone has a stuffy nose for 3 days. Z-paks are AKA "here's this, get out of my face". My rule for abx is they have to have all of the following: URI lasting beyond ~10 days, sinus pressure or tenderness, purulent sinus or bronchial mucus, with or without fever. At that point it's unlikely to be a primary viral problem and the benefits outweigh the risks.

[CAAdmission]

Did you have them hold the phone up to their chest and take some deep breaths?

[ventana]

never for cold s/s

if they are sick enough for ABX they need to be eval

 

UTI is another story - I am male, but having compassion to the females is key - they get UTI's and to force a weekend eval through UC or ER is a waste - guidelines say that you do not need a UC for simple typical cystitis in reproductive age female with out comorbidities. If they are and established patient with "classic" UTI s/s and are reliable I will treat a single time.

I tell them if it does not go away 100% I will have to get a UC

Also recomend they get the UTI test strips from the pharmacy and have them around

Realistically if a reliable established patient, repoructive age female, with classic bladder infection s/s calls in I will "at times" do a phone script. if all the above is not true then no treatment.

 

 

I have saved more person from getting REALLY sick but having them get eval for "cold" prior to prescribing, and saved myself tons-o-scripts for colds.....

 

 

 

as to the original post question - can you bill

 

 

YES but with the chronic care management code - - IF they qualify. >20 min, 3 or more chronic conditions, expected to last, and documentation of such, with a signed ABN on file and policy statement.

 

Seems like a lot to do, but in my geri house call practice I collect 4-5k per year for this code.....

 

 

for the otherwise healthy person - no way to bill

 

I think this is a MAJOR problem with medicine. Try calling any other profession and ask for free advice - never happens. Yet we do it all the time.

 

We need to stop this somehow..... but i have no ideas how.....

[SocialMedicine]

i believe there is some safety data to support treating UTI over phone

However a sexual history over the phone is not that easy and chlamydia can present like a simple UTI and cause PID/infertility if not treated properly

 

Our society has selected a fee for service health system. Why are we delivering this service outside of an office visit over the phone ? More importantly you cannot differentiate viral vs. bacterial over the phone for a URI. I do not treat people over the phone. It is irresponsible on so many accounts. 

[NLRP3]

There is data that shows that females of reproductive age are safely managed over the phone and there is no benefit to seeing them in clinic for uncomplicated cystitis http://www.aafp.org/afp/2011/1001/p771.html  (the link is a little screwy but the title is "Diagnosis and Treatment of Acute Uncomplicated Cystitis" at AAFP.

 

"

Self-Diagnosis and Diagnosis by Telephone

For many patients, access to care can be difficult. Two recent studies have shown that some women who self-diagnose a UTI may be treated safely with telephone management. Women who have had acute uncomplicated cystitis previously are usually accurate in determining when they are having another episode. In one study of 172 women with a history of recurrent UTI, 88 women self-diagnosed a UTI based on symptoms, and self-treated with antibiotics.8 Laboratory evaluation showed that 84 percent of the urine samples showed a uropathogen, 11 percent showed sterile pyuria, and only 5 percent were negative for pyuria and bacteriuria. Another small, randomized controlled trial compared outcomes of acute uncomplicated cystitis in healthy women managed by telephone versus in the office.9 There were no differences in symptom score or satisfaction. The authors concluded that the short-term outcomes of managing suspected UTIs by telephone were comparable with those managed by usual office care."

 

However this is the exception not the rule.

 

URIs are almost never bacterial, especially with a hx of 4-5 days and a low grade temp. If you are concerned enough to prescribe an antibiotic you should see them. 

[LKPAC]

Over the phone may be the future for some of you, but it is bad practice.  It won't take long for patients to know which "magic words" to say to get what they want.   It opens the door to trouble, and I promise it will be indefensible in malpractice court.  Where will it end?  If we do UTI and URI over the phone today, we'll be doing pneumonia and epigastric pain tomorrow.  My physical assessment is too valuable to give up.

[Reality Check 2]

LKPAC - this has been my increasing fear of telemedicine and how corporate medicine has latched on to like the cash cow they want it to be.

 

If I am looking at someone on skype with shortness of breath and a cough - I can't squeeze their calf muscles or hear the difference between rhonchi and wheezes.

 

A lot of places are counting on telemedicine to save the world and break the bank. I feel it is fraught with misdiagnosis and is insane.

 

The telephone is also fraught with those issues - the patient who says "it hurts a little" might be in dire pain and having a dissecting aorta or just have a back sprain. The person with the cold might actual have influenza or pneumonia. 

 

So, I too support the idea of the hands on exam as being irreplaceable. 

[LKPAC]

LKPAC - this has been my increasing fear of telemedicine and how corporate medicine has latched on to like the cash cow they want it to be.

 

If I am looking at someone on skype with shortness of breath and a cough - I can't squeeze their calf muscles or hear the difference between rhonchi and wheezes.

 

A lot of places are counting on telemedicine to save the world and break the bank. I feel it is fraught with misdiagnosis and is insane.

 

The telephone is also fraught with those issues - the patient who says "it hurts a little" might be in dire pain and having a dissecting aorta or just have a back sprain. The person with the cold might actual have influenza or pneumonia. 

 

So, I too support the idea of the hands on exam as being irreplaceable. 

 

I agree.  IMO the only role for telemedicine should be places that are too remote for hands-on to be practical, and therefore telemedicine is better than nothing; or specialty consults when a provider is with the patient and the specialist is remote. Telemedicine should otherwise never be the new standard or an "easy alternative."

[TWR]

FYI all,  This was not me but  wanted to know if we could bill for telephone conversations and RX's.  THAT was the question.

[jmj11]

I agree.  IMO the only role for telemedicine should be places that are too remote for hands-on to be practical, and therefore telemedicine is better than nothing; or specialty consults when a provider is with the patient and the specialist is remote. Telemedicine should otherwise never be the new standard or an "easy alternative."

We use telemedicine very successfully for follow ups (only after hands on evaluation) because most of our telemedicine patients live more than 400 miles from us. Headache patients are so discriminated against that I am doubtful that any PCP would sit there and be the provider in front of them while I was on the other end. They might do it for a cardiologist but to most providers severe headache problems are seen as not real, "drug seeking" and etc. (which is absolutely not true). There are only 4 Headache Medicine clinics in the entire Pacific Northwest and none in Alaska. This service has been a godsend for those patients who would have to drive in or fly in for their appointments.

 

One of my virtual patients flew in from Boise yesterday for her Botox (every 90 days) and that was quite an expense for her. If she had to fly in for every appointment would be a huge problem for her.  If you are talking about virtual appointments for a stranger with a new complaint, then I would mostly agree with you.

[LKPAC]

We use telemedicine very successfully for follow ups (only after hands on evaluation) because most of our telemedicine patients live more than 400 miles from us. Headache patients are so discriminated against that I am doubtful that any PCP would sit there and be the provider in front of them while I was on the other end. They might do it for a cardiologist but to most providers severe headache problems are seen as not real, "drug seeking" and etc. (which is absolutely not true). There are only 4 Headache Medicine clinics in the entire Pacific Northwest and none in Alaska. This service has been a godsend for those patients who would have to drive in or fly in for their appointments.

 

One of my virtual patients flew in from Boise yesterday for her Botox (every 90 days) and that was quite an expense for her. If she had to fly in for every appointment would be a huge problem for her.  If you are talking about virtual appointments for a stranger with a new complaint, then I would mostly agree with you.

 

This is a very good use of telemedicine, IMO.  

[UpRegulated]

Did you have them hold the phone up to their chest and take some deep breaths?

 

I think there's an app for that.

 

 

 

 

 

:) !

[LIPPER]

Not good for business to turn people away "matter of fact" by phone. They'll end up going to a walk-in clinic and if they don't have any really major issues then likely you'll lose them as a long-term patient. Sometimes you have to give a little, to get word of mouth referrals.

 

 

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