The only time I code for a consult is if I don't plan to see the patient after that visit. Usually that's a case where there are warning signs of a difficult patient - multiple pain clinics, drug-seeker, h/o noncompliance, etc) and I want to lay an eyeball on them before deciding if I'll treat them.
If it's a good referral source sometimes you just have to take a bullet now and then.
Narcotics are not for everyone. It is perfectly legitimate to make the patient an offer such as "any type of pain management they want except for narcotics" or offer only suboxone or methadone for analgesia. If they refuse, THEY rejected YOU, which I usually find preferable.
In any case, if things don't work out call the referring doc the minute the patient leaves, because they are going to call that doc from their car and trash you. You need to register your side of the story first.
The referring docs usually know what they have sent you so they aren't surprised at the outcome of the referral. Chances are they are sick of dealing with the patient themselves. I have never had a referring doc call me to pressure me to prescribe. I guess if they did I'd explain why I won't.
Sometimes the PCPs dig themselves a hole with pain meds and expect us to fill it in. That in itself is not a sin, but if the patient needs detox then they are in the wrong office.
Here's how I deal with the "drugs vs other treatment" issue. I tell the patients my criteria for opioid prescribing:
1. An acute pain problem that is expected to be self-limiting (sprained ankle, postop pain, etc).
2. A persistent pain problem that requires analgesics for comfort while the patient awaits tests and/or procedures and/or other types of treatment (psych, PT, etc). Lumbar radiculopathy is a good example.
3. A persistent pain problem that has been refractory to everything we can reasonably try. Perhaps a CRPS patient has failed to thrive with PT, blocks, co-analgesics, SCS, etc. Time to revert to chronic opioids, with or without a pump.
4. A patient with persistent pain whose supervening medical conditions preclude other types of treatment. The typical example is a patient with a fresh coronary artery stent. Or perhaps chronic thrombocytopenia precludes consideration of blocks, a pump, or a stim.
If they don't fit into these criteria they don't get meds. This might happen in the middle of treatment, not just the beginning. For example, a patient who has some persistent pain after LESI and they want meds but refuse PT. They just fell out of category #2.
I tell them they have the right to refuse any treatment offered but that I have the right to refuse to participate in a treatment plan that I disagree with. They usually ask me where they will find someone who will prescribe them the drugs they want, and I tell them they need to look for a doctor who shares their treatment philosophy. If they can't find a doctor who shares their point of view maybe they need to change their point of view.
If the PCP is writing methadone to treat the heroin addiction, he is in violation of the controlled substances act, and can lose his DEA license. The PCP may need to have this information imparted to him. Methadone, for the treatment of heroin addiction, requires a special DEA methadone license that is usually given only to addictionologists in drug rehab centers.
How do you clssify a new pt visit as consult or referral
Would you consider a Neurosurgical, Orthopeadic, Pain Physician, or PCP referral for an "epidural or interventional injection" a consult?
Assume they have filled out a prescription for a "consult" and on their clinical notes they expect the patient to "return for follow up 3wks post injection."
It may turn out that you take over the medications or even modify them.
Ultimately you are being consulted and providing a treatment. I don't always assume that most physcians are trying to "transfer care" or dump their patients, it just happens over time...
Every case is unique. In a complex case with many pain generators, I usually bill a New pt comprehensive.
Right or wrong, the method I've adopted for the time being is as follows:
1. Patient referred on few meds, MRIs already done, it says LESI on the referral script (occasionally a stim trial is requested)--generally billed as consult and returned to the PCP after injection
2. Complex pain problem (notes indicate increasing meds over a period of time, then "refer to pain management"--billed as new patient.
3. Same type of patient as #2, recommendations made but not accepted into the practice--billed as consult.
That was very helpful.
The patient with the heroin problem (the PCP wanted me to take over Methadone prescriptions), I wrote in consult that he was not a candidate for opioids and that he needed a detox program. I then stated that I would have our staff look for a conveniently located detox program for the patient. Hopefully the PCP will appreciate the effort.
Had another one the other day. Patient with long history of migraines referred fo opiate management. Come to find out he was also referred to a Neurologist who is still treating her (diagnosed her with Greater Occipital Neuralgia-I concur) and a Psychiatrist for his significant anxiety and depression. He was referred to our practice to continue the Avinza (at least she was switched off of Oxy), Diaudid, Soma and Ativan.
After reviewing referal notes find that he also has C2/3 facet and maybe anterior joint pain from several past MVAs. I D/C Ativan, Soma and Dilaudid, increase Avinza and recommend C2/3 facet/OA/AA injections and depending on the response, a trial of GON stim. Patient argues for about 5 minutes, then takes the prescription and leaves.
I don't think this one's coming back either.
write her a discharge letter.....you have nothing to gain by keeping noncompliant patients in your practice.
i also made it clear to the community docs that i don't prescribe narcotics so therefore there is no need for "transfer of care"... the ones who still send me their narcotic patients i tell them that further narcotics are inappropriate in my opinion and recommend a wean - don't get many of those referrals anymore.../
99% of my visits are coded as consults
1) i require that every physician refer them to me for consultation
2) any patient who i see who hasn't been referred is coded as new patient instead of consult
3) i send a report back to the patient with my impression and recommendations...
i also made it clear to the community docs that i don't prescribe narcotics so therefore there is no need for "transfer of care"... the ones who still send me their narcotic patients i tell them that further narcotics are inappropriate in my opinion and recommend a wean - don't get many of those referrals anymore...
the CMS has made clear what constitutes a consultation and I can document everything in my chart (the letter the referring physician sent over to me, the letter back, etc...)
1) show me data that chronic opioids improve pain scores or outcomes (you cannot include cancer data nor can you include any short-term studies <12 months)
2) now look at all the data on long-term use of opioids - none of it is about functional improvement, it is all about side-effects, complications, etc...
3) PCPs prescribe narcotics on their own - why is it my responsibility to take over they faulty decisions?
4) if the patient is using the narcotic appropriately and showing good maintenance then the PCP isn't going to send that patient - they are only going to send the patients that in my opinion should never have even been started on those narcotics and now the PCP is in a bind. they send those patients to me - i evaluate them and send back my recommendations with a wean.... the PCPs LOVE THIS because it gives them an official out from a situation they dug themselves into... best example i can think of are the alcoholics who are abusing their vicodin...
5) i prescribe narcotics when i think it is appropriate (primarily nociceptive pain) and if there is evidence of functional improvement and improved pain score - which is about 2% of all consults....
6) i am in a semi-competitive market and I get 11-14 referrals per day and see between 6-9 new patients per day (5 days a week)... surprisingly more and more of those referrals are strictly for interventional approaches and less and less are for narcotics...
talk about a self-fulfilling prophecy...
there is this misconception that to make PCPs happy you have to take their scum.... well guess what? if you do a good job and build a reputation of offering primarily interventional approaches to pain, then those are the consults you are going to get.... the PCPs are smarter than you think and will find another pain dr to dump the narcotics on... which is what has happened to the pain clinics around me....
by the way i challenge you to show me the data - because if you find convincing data I may change my practice to reflect that...
I agree with Gorback. I have the following things to add (you are again giving me tenesmus):
1) You seem to contradict yourself in your last few posts. First you say that you tell PCP's that you do not prescribe any narcotics. Then, you say that you prescribe it to 2% of your patients. I think that even you would agree that these two statements are mutally exclusive.
2) You say that the reason that you do not prescribe narcotics as they there are no studies to document efficacy after 12 months or in nonmalignant pain. No, there are not any studies. But dont pretend that this is the reason that you are not prescribing opioids. There are no good studies that show that epidurals are effective after 12 months but I bet you perform many of these procedures. Give me a break......You need to use your own clinical experience sometime. I am sure that you have a few if not many patients who are able to keep a job or improve their function on opioids. You should know that double blinded, randomized control studies are difficult to perform in interventional pain management. I do not feel that you should continue opioid treatment in patients who are showing no progression in treatment or improvement in function. However, to wash your hands of all patients on opioids is irresponsible and a let down to your community (as you are supposed to be the expert).
In short I feel that you need to get out of the business. I know that this is a strong statement but this is how I feel. The real reason that you dont want to prescribe opioids is that either you want to make more money by doing procedures or that you have a lack of education about the drugs. If you were not taught about appropriate opioid management in fellowship then your preceptors failed you. I feel sorry for your patients and their referring providers. Lastly your "scum" comment is demeaning and insensitive.
sorry about the delay in getting back...
1) i did a fellowship and am sub-specialty board certified in pain - and my faculty are top-notch authorities on narcotics (one of them has a 7 PHD lab dedicated to the study of narcotics).... in fact i recommend some reading on opioid-induced hyperalgesia as this is a growing concern...
2) i mis-spoke i don't physically prescribe the narcotics - i recommend prescription of narcotics in about 2% of consults I see. Patients who demonstrate functional improvement on them without ANY red flags and who have organic disease that isn't responsive to other modalities
3) prescribing narcotics - i don't prescribe or recommend prescribing them for most patients for 2 reasons - lack of evidence showing improvement in outcome AND massive evidence of societal impact, long-term side-effects, etc...
4) i have chosen to focus my work on the interventional non-narcotic approach to back pain - just like electrophysiologists primarily do pacemakers and AICDs....
5) money: procedures are good money, but I have a few friends in florida who make more money than I do and they are 100% pharmacologic management... so if you have a good head for business, and are efficient you can make a good living no matter what... the key is to minimize overhead in the safest ways possible..
6) epidurals: there are no studies to show that epidurals are good for long-term control - in fact most studies suggest that at best they are helpful for short-term control and according to some studies even that is a stretch... Outcomes and Side-effects between epidurals and opiates cannot be compared --- you can't compare oranges to apples
7) getting out of business? well maybe that is what the pain clinics around me are hoping for.... but the feedback I get from the PCPs has been good (they love the fact that I don't prescribe narcotics - in fact, they are pissed off with the amount of narcotics that are coming out of surrounding pain clinics).... and the feedback I get from MOST of the patients I see has been good... they will frequently tell me that their pain score is unchanged despite being weaned off the narcotics, but at least they can have sexual desire again and don't have to deal with the constipation.... the patients who aren't happy with my recommendations have the following "red flags" and thus fall into my "scum" category 1) full disability but they can't remember why they are on disability 2) history of doctor shopping to get vicodin/soma 3) unwilling to consider any alternative pharmacologic treatments 4) non-compliant with most treatment recommendations 5) no clearly delineated organic disease - and 6) hx of drug abuse or active alcoholism....
--- now if your experience is vastly different from mine, and you find that most of your patients do very well on narcotic regimens, then please let me know which criteria you use and what drug combos work the best because it would be an extra feather in my cap if I could help more patients...
This is a rather unique interpretation of the definition since it requires the receiving physician to be a mind reader. Although there is a lot of language there about the intent of the referring physician, the key principle is "transfer of care". The referring doctor may intend for you to accept the transfer of care, but it does not actually occur until you accept the transfer.
It would be interesting to see a panel of coding experts argue this issue, where the referring doctor intends a transfer of care but the receiving doctor refuses. I'll bet we get differing opinions.
No need for ESP - David Vaughn, ESQ, CPC, in Baton Rouge devised a form you fax to your referring physician with the exact verbiage.But what I really think is they purposely made it difficult so we give up... just more cognitive dissonance by Big Brother.
Never attribute to malice that which can be explained by mere stupidity.
When it comes to billing, the best advice is to not be a standout. The tallest patches of grass usually get cut first.
Silly silly Gorback - it is whatever medicare says it is, and so long as you meet THEIR definition (as opposed to the logical, reasonable, or dictionary definitionsYou can call your reports Valentine's Day cards, but if you initiate treatment it still isn't a consult.
No need for ESP - David Vaughn, ESQ, CPC, in Baton Rouge devised a form you fax to your referring physician with the exact verbiage.
He/she checks off the appropriate response, puts a copy in his chart, and faxes his completed form back to you. Al done by your staff, no time or work for you, and completely complies with the current coding requirements.