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They probably ordered a CTA runoff to "help you out" and make rads have a stroke about reading another runoff on someone for zero reason lol
Consults- Memorable/Dismal/Ridiculous/Unique
- Thread starter surgres88
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Even better are the ones that get an outpatient ABI study and it shows decreased pulses, so their PCP sends them immediately to the ER on a Friday afternoon which bums the patient out since now they have to miss their golf game or whatever. Sadly, the ER generally will admit these people who just need an outpatient clinic visit eval.
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Please stop triggering me.
Also the ED PAs are lighting up my phone the past few days at this one locums site with asymptomatic popliteal DVTs that are indeterminate age on US and then when I ask if there are any prior studies, there are like 6 that all show the same thing but they just didn't look for it. And things like splenic and renal infarcts that don't involve anything vascular intervenable and then want me to tell them how to work it up. I finally told one today that UpToDate had an excellent article and I reviewed it myself before talking to him since I don't typically deal with these when there's no dissection, aneurysm, mural thrombus, FMD, or main renal artery thrombosis.
Today a hospitalist asked me if I could help set up a patient for an event monitor. I'm sorry sir that's not my area.
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Had a great consult the other day... patient admitted for a NSTEMI, was asked to see because they couldn't palpate distal pulses after his cath. Oh, and when they tried to cath him from the right groin they couldn't so they went to the wrist. Of course, a casual look at outside records showed he has known occlusion of the juxtrarenal aorta and iliacs for several years. Legs were a bit numb earlier in the day, but back to baseline at the time of the consult. Oh, and he needs heart bypass so he's transferring out.
Great consult!
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ER:
I have a very difficult to control nosebleed I was hoping to get your help with.
Me:
Ok. What’s the story?
ER: patient on asa. Was in a different Esr yesterday and bleeding responded to afrin. She presented today and we tried that but it didn’t work. So we got her blood pressure normalized and put in a pack. The pack was in for 1-2 hours but we pulled and it didn’t work.
Me:
..(something weird about this)
What’s her BP?
ER:
Oh, it’s down to 160/93 now.
Me:
I wouldn’t call that normalized, but…I want to verify something. You said the pack was in for 1-2 hours and it didn’t work, right? Does that mean she was bleeding around the pack?
ER: no. She wasn’t. She started bleeding again when I pulled the pack out.
Me:
Did you consider leaving the pack in there? Like we usually do?
ER:
You can leave it in?
Me:
Yeah, man. You can leave it in. Have her see me in 72 hours….
I have a very difficult to control nosebleed I was hoping to get your help with.
Me:
Ok. What’s the story?
ER: patient on asa. Was in a different Esr yesterday and bleeding responded to afrin. She presented today and we tried that but it didn’t work. So we got her blood pressure normalized and put in a pack. The pack was in for 1-2 hours but we pulled and it didn’t work.
Me:
..(something weird about this)
What’s her BP?
ER:
Oh, it’s down to 160/93 now.
Me:
I wouldn’t call that normalized, but…I want to verify something. You said the pack was in for 1-2 hours and it didn’t work, right? Does that mean she was bleeding around the pack?
ER: no. She wasn’t. She started bleeding again when I pulled the pack out.
Me:
Did you consider leaving the pack in there? Like we usually do?
ER:
You can leave it in?
Me:
Yeah, man. You can leave it in. Have her see me in 72 hours….
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Regarding primary care/Er/PA/NPs not knowing what the scope of your practice is:
That is what being an ENT is all about! No one seems to have any idea what we do or don’t do.
I got a call yesterday, a very common call, wherein a 32 year old female was having molar pain for a week. Now she’s having swelling around the angle of her mandible and trismus. CT shows no abscess.
I said “ok. Sounds like she should see a dentist about that molar.”
ER says “yeah, but I can’t refer to a dentist and we don’t have a dentist on staff…”
I said “ok, but…I’m still not a dentist. If you’d like to take a crack and pulling her molar, you and I have about the same amount of experience.”
I get weekly calls for “rash on the face.”
I get weekly calls for “facial cellulitis, no abscess.” I mean…what do I have to add to that? If it was on the leg would you call gen surg or ortho?
Consult for oral herpes! Cool. Do you know what the current standard is for that? I’ll have to google it. Probably some kind of anti-viral?
“Sinus headache!” With 34 scans in the last year demonstrating no evidence of sinusitis and the patient has no symptoms except their face hurts.
Hypothyroidism. Admittedly this is an easy one that I can in fact manage, but so can your medical student.
Got a call from an outside hospital where I’m not credentialed for a 41 year old woman with “no medical history” who had a strep bacteremia. She had become encephalopathic, non responsive to commands, trouble with secretions. No airway problem, yet. They were wondering if tonsillectomy might be indicated.
Any scans?
No
What’s her throat look like?
Not sure, she won’t let me look.
When are you planning on intubating this confused, drooling, decompensating septic patient who’s throat you’re clearly worried about because you’re calling me?
“Do you think we should?”
……yes….call your anesthesiologist or critical care doc and intubate her. Call me when you have a scan. If you think she needs a trach call your staff surgeon.
Scan showed no throat abscess. Turns out strep can come from other places. Who knew?
That is what being an ENT is all about! No one seems to have any idea what we do or don’t do.
I got a call yesterday, a very common call, wherein a 32 year old female was having molar pain for a week. Now she’s having swelling around the angle of her mandible and trismus. CT shows no abscess.
I said “ok. Sounds like she should see a dentist about that molar.”
ER says “yeah, but I can’t refer to a dentist and we don’t have a dentist on staff…”
I said “ok, but…I’m still not a dentist. If you’d like to take a crack and pulling her molar, you and I have about the same amount of experience.”
I get weekly calls for “rash on the face.”
I get weekly calls for “facial cellulitis, no abscess.” I mean…what do I have to add to that? If it was on the leg would you call gen surg or ortho?
Consult for oral herpes! Cool. Do you know what the current standard is for that? I’ll have to google it. Probably some kind of anti-viral?
“Sinus headache!” With 34 scans in the last year demonstrating no evidence of sinusitis and the patient has no symptoms except their face hurts.
Hypothyroidism. Admittedly this is an easy one that I can in fact manage, but so can your medical student.
Got a call from an outside hospital where I’m not credentialed for a 41 year old woman with “no medical history” who had a strep bacteremia. She had become encephalopathic, non responsive to commands, trouble with secretions. No airway problem, yet. They were wondering if tonsillectomy might be indicated.
Any scans?
No
What’s her throat look like?
Not sure, she won’t let me look.
When are you planning on intubating this confused, drooling, decompensating septic patient who’s throat you’re clearly worried about because you’re calling me?
“Do you think we should?”
……yes….call your anesthesiologist or critical care doc and intubate her. Call me when you have a scan. If you think she needs a trach call your staff surgeon.
Scan showed no throat abscess. Turns out strep can come from other places. Who knew?
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Unfortunately, the answer is very much yes they do call us 🤦♂️
Except they try and throw around the term nec fasc to justify calling
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Oh yes. Yes they do.
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Unfortunately, it's just venous stasis changes...
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Yes. OR it’s cellulitis in the setting of venous edema. Then at least I can provide recs for compression because no one ever does if vascular isn’t consulted.
OR it’s not cellulitis, it’s dependent rubor from severe PAD and that gets missed a lot. So again good when I’m consulted even if for the wrong reason. Not all redness is cellulitis! My favorite “magic trick” is elevating the leg for the ED folks and watching the “cellulitis” disappear. I’m a magician!
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See? At least you have something to say beyond “ah…put them on antibiotics?”
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I do now that I’m vascular. When I was gen surg… not so much.
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Probably unrelated to everything above:
The Miseducation of America’s Nurse Practitioners
The Miseducation of America’s Nurse Practitioners
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I feel this deeply in my soul.
I'd like to think it's a local problem. But I don't think we're even close to the same area of the country and this sums up my weekly rants nicely. How is it so unclear what our jobs are? Why am I the only person that can order scans and manage things? I've decided I'm everyone's phone a friend. Uggh
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Youre not gonna believe this....
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<4am>
Phone: <Ring ring>
Me: <Bleary eyed> Dr. LucidSplash for vascular.
ED doc: <at hospital I am on call for phone consults but does not have inhouse vascular coverage, meaning I can’t go see the patient and can only have them transferred to me if I think they need it based on ED report>: Hey sorry to wake you up. I have a guy here who came in because his arm suddenly went numb tonight. He has an upper arm fistula for several years that’s he’s never used, he had some sort of event and was on dialysis awhile but then came off of it. Anyway, the fistula is like a C-shape which he says his PCP says is new and wanted him to go get it checked out awhile ago but he didn’t because he wasn’t worried about it. It has a good buzz in it <actual words used by doctor>. But now his arm is suddenly numb. I was gonna set him up for outpatient but I figured I’d give you a call and ask what you thought might be going on.
Me: …
Me: <Checks time>
Me: I mean, does he have a pulse in the wrist? Is just the hand numb or the whole arm?
ED: Oh yeah, arm and hand are warm and with a good pulse. The whole arm is numb he says. But the fistula is C-shaped. So wondering why his arm is numb. He’s pretty worried about the numb arm.
Me: … What kind of workup for the numbness have you done?
ED: Nothing. I figured you’d know what was wrong with it.
Me: <Mustering mature adult deep inside> I think it’s unlikely that there is any vascular cause to an arm that suddenly went numb in the middle of the night, if said arm is warm with a good pulse. The fistula is a red herring and I’d recommend working him up as you would anyone with a suddenly numb arm that doesn’t have a fistula. That sounds concerning.
ED: Ok yeah I’ll set him up for outpatient then. Thanks.
🤯
Phone: <Ring ring>
Me: <Bleary eyed> Dr. LucidSplash for vascular.
ED doc: <at hospital I am on call for phone consults but does not have inhouse vascular coverage, meaning I can’t go see the patient and can only have them transferred to me if I think they need it based on ED report>: Hey sorry to wake you up. I have a guy here who came in because his arm suddenly went numb tonight. He has an upper arm fistula for several years that’s he’s never used, he had some sort of event and was on dialysis awhile but then came off of it. Anyway, the fistula is like a C-shape which he says his PCP says is new and wanted him to go get it checked out awhile ago but he didn’t because he wasn’t worried about it. It has a good buzz in it <actual words used by doctor>. But now his arm is suddenly numb. I was gonna set him up for outpatient but I figured I’d give you a call and ask what you thought might be going on.
Me: …
Me: <Checks time>
Me: I mean, does he have a pulse in the wrist? Is just the hand numb or the whole arm?
ED: Oh yeah, arm and hand are warm and with a good pulse. The whole arm is numb he says. But the fistula is C-shaped. So wondering why his arm is numb. He’s pretty worried about the numb arm.
Me: … What kind of workup for the numbness have you done?
ED: Nothing. I figured you’d know what was wrong with it.
Me: <Mustering mature adult deep inside> I think it’s unlikely that there is any vascular cause to an arm that suddenly went numb in the middle of the night, if said arm is warm with a good pulse. The fistula is a red herring and I’d recommend working him up as you would anyone with a suddenly numb arm that doesn’t have a fistula. That sounds concerning.
ED: Ok yeah I’ll set him up for outpatient then. Thanks.
🤯
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Speaking of your friendly neighborhood stroke alert, I had someone on for a somewhat urgent case but it’s closer to elective. I get word that it was canceled, no biggie.
ICU: Hey, we have your patient. They had a couple very large strokes. We and the spouse were wondering if you could come to the hospital (where I don’t have privileges, staff, or the equipment needed) to do the case while he’s inpatient.
Me: …unfortunately that’s not possible.
ICU: OK, well we could transfer the patient from our stroke center to a place you have availability (that has no stroke coverage).
Me: …yeah, that also seems like a bad idea. Maybe we focus on priorities and I’ll get it done ASAP when they’re doing better.
Just jeez.
ICU: Hey, we have your patient. They had a couple very large strokes. We and the spouse were wondering if you could come to the hospital (where I don’t have privileges, staff, or the equipment needed) to do the case while he’s inpatient.
Me: …unfortunately that’s not possible.
ICU: OK, well we could transfer the patient from our stroke center to a place you have availability (that has no stroke coverage).
Me: …yeah, that also seems like a bad idea. Maybe we focus on priorities and I’ll get it done ASAP when they’re doing better.
Just jeez.
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Twist: the patient is here this am admitted to hospitalist, there is a note that says vascular agreed to transfer.
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Of course
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"G damn that guy!!!!"
"Vascular says clear for discharge, no further workup needed"
"Vascular recommends emergency transfer to vascular-capable center for neurosurgery consult, please consult vascular on arrival as it's their patient. And please make sure to consult neurosurgery before anyone sees the patient or does any further workup"
"MDM: I am concerned about AV fistula, stroke, cord compression, cauda equina, GBM, ICH, PE, AAA, STEMI, NSTEMI, CPAP, BIPAP, RN, MSN, DNP"
"I spent 93 minutes of critical care time managing this patient by waiting on hold with the transfer center"
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This is an accurate representation of our ED notes (always blank templates and filled in 2 days later).
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Don’t yall have someone on admit on the call the whole time? We always have a nurse. The older ones are usually pretty good at least telling me, the Hospitalist, when the other doc straight up makes stuff up or has “inconsistent” history.
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Sometimes the ED calls me directly, and I called them back directly, sometimes there is an intermediary that stays on the phone. in this case, the ED called me directly.
Just saw an otherwise healthy 20 year old patient in clinic who was referred for a single case of strep throat that already resolved with antibiotics.
Thank you for this interesting consult. No you do not need a tonsillectomy, sir.
Thank you for this interesting consult. No you do not need a tonsillectomy, sir.
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“I couldn’t get in to my PCP/don’t have a PCP so urgent care sent me to you…urgently….”
Every day, at least one. It’s the best use of medical resources.
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How much control do you guys have over what gets seen in your clinic? I never paid much attention to this aspect of things in training so not sure how everyone does it. I know some places like Kaiser micromanage all of that for you while others let docs be more choosy.
I saw a lot of those bs consults get scheduled at first and my senior partners all complained about it too. Once they retired a few months ago and left me flying solo, I just took it upon myself to personally triage every referral and I haven’t seen a crappy urgent care referral ever since. I see it as triaging my very limited time when ent availability is so limited here, and even with me mass rejecting all the bs for months now I’m still booking into late 2025 for new patients. Clinic is more fun too because every patient actually needs something only an ent can provide, be it surgery or an office procedure.
Is there a reason everyone doesn’t do this? Admin? Risk of offending referring docs? Market dynamics in your area? Other?
I suspect the latter - probably couldn’t get away with this in a saturated market because referring docs would quickly stop sending patients.
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I do screen.
The problem is that documentation is so poor that it’s sometimes hard to determine what to do. The UC note says “sore throat for a week” and when we call the patient he says he’s had strep nine times in a year or what-have-you.
Or just the opposite. The patient is told they have strep and referred routinely but they have cancer. I’ve seen that twice this year.
It’s not common, but it’s common enough that I find it hard to know for sure in many cases. The fact that 75% of UC notes are boilerplate normal followed by a bullet at the end saying the patient “has a PTA” doesn’t make it easier.
So I do screen out the truly crazy ones (patient with a diagnosis of delusional parasitosis referred for facial lesions) or the rare case in which the doc has already ruled out the problem for which they’re sending a patient and it’s documented.
I also don’t see a lot of crap that imho is better served elsewhere. We have an oral medicine doc for burning mouth patients. I don’t see oral thrush. I don’t have anything to add to that. Find out why they’re immunosuppressed and put them on nystatin or an oral anti-fungal. That’s it. Sending them to me is just asking me to do your job for you.
That kind of thing.
Some of it is marketing. PCPs can get pretty angry when you don’t eat the $#!t sandwich they made for you. And many times when I deny a referral they will just refer them again. I’m in an employed position. So we have a lot of freedom for denying BS, but I imagine if we said no to all the ridiculous stuff (which is a good 30% of all referrals) we would start to see some pushback.
We’re in an area where the patients don’t have a ton of other choices, so I don’t worry too much about them going elsewhere, but I imagine that’s a major concern in an urban area.
I also have partners and while the younger ones are happy to not waste their time and resources on BS, the older ones still have a mindset that anything referred to them is worth seeing (and billing for). I think there’s a generational difference there.
When I was in the Army I screened 100% of everything and saw nothing that did not have a documented indication for ENT referral. It was -awesome.- But it was a different patient population and a different pecking order.
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They need a disposition for these people. And it's not a primary care. Unfortunately It's a surgical specialist. It's exhausting. I have printed copies of the Paradise Criteria that I hand out
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Good discussion.
It's many factors. For me. I'll see you and tell you nothing to do or whatever. It's annoying. But I just see it as easy money. We have a PA screen things and make sure they've had at least an ultrasound for the "neck mass" prior to coming. Or a cxr for chronic cough. We're a bit afraid of losing referrals if we push back too much. But that might be self imposed more than reality.
As we've belabored in the past, the quality of the referral seems directly tied to the level of education achieved by the referring "provider"
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I knew a general surgeon a while back who used to respond to my complaining about poorly trained midlevels by saying that undereducated NPs and bad docs were his favorite clients because they provide a constant stream of easy, billable encounters.
And I get that. I really, really do.
I also have a very hard time stomaching the idea of billing a patient for a service they don’t really need. It’s an internal thing. I wish I could turn it off.
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I totally feel that. And I respect that you feel that way.
I have convinced myself that if no one else they see is going to have a clue what to do, no matter how mundane, then I'm going to "save" the patient and help get them on the right track. I rationalize that if they're willing to spend their money to pay a severely undertrained provider, then they should be more than happy to pay a trained doctor who can either reassure them or actually help them. It's mental gymnastics that I've been able to assuage my conscience with.
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Facts.
I do spend time educating. A lot of time. Probably as much or more when the patient has been through the primary care misdiagnosis gauntlet. I try to give them some idea of what’s going on (and why it isn’t eustachian tube dysfunction), and I do tell myself that they’re at least getting something for their money. But then I remind myself that their NP got paid for doing jack and $#!t with no effort, and I get angry again.
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This is super valid especially if even if you personally don't do anything for the patient you end up getting them referred to the right place or assure the patient the problem doesn't need an intervention.
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I think the follow up to that is: at what level should there be an expectation that appropriate disposition is made? It seems to me that knowing where to send a patient is really the base function of an urgent care or ER. So while I don’t disagree that Pir8 is providing a service, what seems ridiculous is how often patients need to see a specialist just to get a referral to another specialist. I’my clinic, even with a modicum of screening, it’s somewhere between 10-30% of what I see.
We have an overworked, strained medical system that we are patching with the band aid of midlevel practitioners which actually seems to be exacerbating the problem. I’m just not sure hiring more people who aren’t expected to make a good diagnosis in order to feed a diminishing number of specialists who can appropriately refer is a sustainable system.
And I get that it is the nature of the uncertainty of medicine that this will sometimes happen no matter what. But it seems like it’s a little too common.
So I agree that Pir8 is doing a good deed. I just think that the system that puts him in that position is raw dawging patients with needless visits and expense because we can’t seem to train people correctly at the front end.
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Imagine going to a restaurant. There’s an open table. Half the people showing up to eat can go straight to a table to eat, but your diners insurance doesn’t allow that. So you go to the hostess and tell them you’re hungry and they say “great, because we serve food” and you say “great I’ll have some food” and they say “well I don’t know how to make food. But if you pay me $50 I’ll get you a table.”
So you pay. And you wait an hour. And you get a table. And then the waiter comes over and says “hey, great to have you. What can I get you?l and you say “food” and the waiter says “ah, sorry, I don’t serve food. I only do cocktails. Do you want a cocktail?”
And you don’t. (I know, unrealistic but bear with me) and you say “nah, I just wanted food. I told the hostess I was hungry and she put me here. I paid for that”
And the cocktail waiter says “well, I don’t do food. Here’s your bill for cocktail service. But I’ll tell you what, I’ll get a food waiter to come over here!”
And you say “why did the hostess sit me here if you only do cocktails?” And the waiter says “well, she’s a hostess. She didn’t go to cocktail school so she doesn’t really know what a cocktail waiter does. Plus, you know, she’s super busy. But it’s ok, because I’ll get the food waiter. By the way you can settle the bill at the end.” And he gets a food waiter.
You’d never go back to that restaurant.
Now imagine it’s every restaurant and that’s just the way restaurants are.
Also there’s ten hostesses for every one waiter.
So you pay. And you wait an hour. And you get a table. And then the waiter comes over and says “hey, great to have you. What can I get you?l and you say “food” and the waiter says “ah, sorry, I don’t serve food. I only do cocktails. Do you want a cocktail?”
And you don’t. (I know, unrealistic but bear with me) and you say “nah, I just wanted food. I told the hostess I was hungry and she put me here. I paid for that”
And the cocktail waiter says “well, I don’t do food. Here’s your bill for cocktail service. But I’ll tell you what, I’ll get a food waiter to come over here!”
And you say “why did the hostess sit me here if you only do cocktails?” And the waiter says “well, she’s a hostess. She didn’t go to cocktail school so she doesn’t really know what a cocktail waiter does. Plus, you know, she’s super busy. But it’s ok, because I’ll get the food waiter. By the way you can settle the bill at the end.” And he gets a food waiter.
You’d never go back to that restaurant.
Now imagine it’s every restaurant and that’s just the way restaurants are.
Also there’s ten hostesses for every one waiter.
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Absolutely agree. The best option would be if whoever saw them made the right dispo to begin with. But since that isn't happening one can either spend their time uncomplicated screening referrals or see these patients and get compensated for thinking about what they need.
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This is why I only screen the insane ones. Or the patients who have already been ruled out.
Even when I do, the office calls the patient, tells them that we have reviewed their chart, and lets them know if I recommend they see a different specialist. I just don’t give them a bill for it.
And frankly I spend 1/10th of the time screening than I would seeing the patient. It really doesn’t take long. Plus it frees up my clinic time for people who need my services.
But like I said above - no discredit to anyone who feels good about billing for that. I don’t. Despite it being a huge percentage of my business it always leaves me bitter. I’m l not saying my way of thinking is superior and I wish I could just let it go.
When your house is on fire and clearly unsalvageable, it’s definitely better to be able to enjoy the light show knowing you can’t stop it than it is to be worried about the house. I can’t stop thinking about the house. It’s probably not healthy.
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Great discussion friends!
I feel like in an ideal world I would see everything too; it’s the imbalance of supply and demand that pushes me to screen heavily. I think it definitely improves access for those who really need it but I’ve started finding some other ancillary benefits-
1) I’m definitely faster seeing patients who have actual ent surgical problems. The discussions and exams are much faster and plans easier. They also tend to be less likely to devolve into the “let me ask you every possible ent related question while I’m sitting here.”
2) fewer visits per patient. Untreated patients tend to require more follow up visits. The more patients I can dispo in 1-2 rather than 3-4 visits frees up tons of time.
3) decreased no show rate. Since we’re often booking 8-10 months out for new patients, the ones with actual surgical problems will often show up. The ones with self limited issues seem to no show at a much higher rate.
I don’t like that screening them is uncompensated time, but the increased per-visit RVUs of real visits versus crappy ones plus higher show rate makes up for it.
I’ve also found that we can technically bill for the screening (CPT 99451) as well just like I found we can bill for those ER calls (99447-9). The only issue is the infrastructure for dropping the charges. My system lets me do it for the ER calls because I can drop it as a charge on their visit and so far looks like it works; still working on the referral ones because there’s not an encounter per se and sometimes outside referral patients aren’t fully registered in the system.
Actively working with admin on this one so will see what they can do. I feel like many docs don’t know these codes even exist because they’re always surprised when I tell them.
I feel like in an ideal world I would see everything too; it’s the imbalance of supply and demand that pushes me to screen heavily. I think it definitely improves access for those who really need it but I’ve started finding some other ancillary benefits-
1) I’m definitely faster seeing patients who have actual ent surgical problems. The discussions and exams are much faster and plans easier. They also tend to be less likely to devolve into the “let me ask you every possible ent related question while I’m sitting here.”
2) fewer visits per patient. Untreated patients tend to require more follow up visits. The more patients I can dispo in 1-2 rather than 3-4 visits frees up tons of time.
3) decreased no show rate. Since we’re often booking 8-10 months out for new patients, the ones with actual surgical problems will often show up. The ones with self limited issues seem to no show at a much higher rate.
I don’t like that screening them is uncompensated time, but the increased per-visit RVUs of real visits versus crappy ones plus higher show rate makes up for it.
I’ve also found that we can technically bill for the screening (CPT 99451) as well just like I found we can bill for those ER calls (99447-9). The only issue is the infrastructure for dropping the charges. My system lets me do it for the ER calls because I can drop it as a charge on their visit and so far looks like it works; still working on the referral ones because there’s not an encounter per se and sometimes outside referral patients aren’t fully registered in the system.
Actively working with admin on this one so will see what they can do. I feel like many docs don’t know these codes even exist because they’re always surprised when I tell them.
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I hadn't heard of it so good to know. I don't routinely screen but sometimes I do so I will have to look into using that code. I'm lucky enough that I am not booking far out (I only have clinic Wednesday am so if you call Wednesday afternoon for appointment you could see me the following week unless I make a special trip to the office which I do if it is urgent enough) so access to me isn't an issue. I don't like wasting people's time though so I'm trying to train my staff about things they can divert to another surgeon (like hiatal hernia because I don't do them) without asking me but there aren't a lot of those kinds of things for me.
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Agree with all of this
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I, like operaman, am booked out months. The most common first interaction with a patient is:
Me: “Hi!”
Patient: “Do you know how long it took me to get in here?!?”
And then I proceed to explain to them that they don’t actually have a problem I can treat. Then they get frustrated at best, angry at worst.
Undoubtably that makes a difference. I might not feel as bad if it wasn’t delaying care as long as it is to see things that don’t belong in my clinic.
@operaman so when you bill 99451 are you dropping a note to or sending a letter to the referring provider explaining why you’re not seeing the patient? How is that documented?
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Oh yeah I think we must be seeing the same patients. Literally every new visit starts that way now - I’ve got my staff asking people not to get sidetracked about that and focus on the reason they’re here.
So for 99451 I’m still working on that. It definitely needs some kind of written report to justify the code. For the telephone consults I have a note template where I document my findings and then just drop it under that encounter. For the 99451, IT is trying a new way of funneling the internal referrals that may allow me to drop charges. I’ve also thought about just creating an encounter and billing it like any other visit with that as the E&M code, but that takes more time and starts to be not worth it.
I’m going to keep playing with it - seems like there’s potential there. At least until patients start getting bills from some ent they’ve never seen and then start complaining!
ETA: where I’ve used it successfully so far is for inpatient consults where I don’t need to see the patient and they don’t need follow up with me. The issue now is figuring out the logistics of dropping the charge in the outpatient setting.
Today in House M.D. "Mysteries of the Ear"
60ish gentleman with history of hearing loss and hearing aids noted worsened left sided hearing, pressure, and discomfort x 1 month.
Since then, his PCP, audiologist, and his wife (retired RN) have all looked in his ear.
His PCP told him "I don't think it is an ear infection, but let's try some antibiotics anyway just to be sure". This did not help.
He got a hearing test which was not sent with his referral.
He then got MRIs of his brain/IACs and orbits (??!?!?!), as well as a MRA of his head and neck for some reason. All normal.
Today I saw him and noted a HUGE FREAKING HEARING AID DOME in his left ear canal which I pulled out. Hooray, he is cured!
What the literal hell, people
60ish gentleman with history of hearing loss and hearing aids noted worsened left sided hearing, pressure, and discomfort x 1 month.
Since then, his PCP, audiologist, and his wife (retired RN) have all looked in his ear.
His PCP told him "I don't think it is an ear infection, but let's try some antibiotics anyway just to be sure". This did not help.
He got a hearing test which was not sent with his referral.
He then got MRIs of his brain/IACs and orbits (??!?!?!), as well as a MRA of his head and neck for some reason. All normal.
Today I saw him and noted a HUGE FREAKING HEARING AID DOME in his left ear canal which I pulled out. Hooray, he is cured!
What the literal hell, people
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Well, you would have to look in the ear to see that and that’s not something you can expect a primary care provider to do.
Incidentally the MRI didn’t mention an occluded canal?
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I had to Google “hearing aid dome” thinking maybe it was some kind of cast of debris that forms from wearing hearing aids or something.
I was not expecting it to be part of the hearing aid itself. Yeah. Super yikes.
