Dispensing insulin w/ sliding scale

[Curiousone1111]

hey guys,

I got an rx for novalog “40 units tid, with additional insulin per sliding scale up to 200 units/day.” Verified dose with office. For billing purposes, are we supposed to bill days supply as if they got 200u/day? say you dispense a box which has 1500 units/200u per day= 7.5 days?

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[WorthlessOxygen]

The pharmacies that I've worked at have always billed that way, to my knowledge we haven't had any issues with audits yet.

 

[wagrxm2000]

hey guys,

I got an rx for novalog “40 units tid, with additional insulin per sliding scale up to 200 units/day.” Verified dose with office. For billing purposes, are we supposed to bill days supply as if they got 200u/day? say you dispense a box which has 1500 units/200u per day= 7.5 days?

Yep, never seen an audit.

 

[spacecowgirl]

Ah sliding scale insulin - nothing like trying to control sugars by reacting to what has already happened. SSI should not be used except maybe as a short term correction in addition to scheduled doses.

 

[confettiflyer]

Ah sliding scale insulin - nothing like trying to control sugars by reacting to what has already happened.

Almost as good as STAT Lantus. Almost.


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[spacecowgirl]

Almost as good as STAT Lantus. Almost.


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STAT nicotine patch. Really any patch for that matter .

 

[Sine Cura]

I wouldn't be surprised if SSI is just an excuse or tactic to reduce office visits or sending new Rx. Just tell the pt what they are supposed to be on. How many times has a patient told you what they are actually taking and it is completely inconsistent with the sig, not because they misunderstood the sig but it's what they claim the prescriber said? Most of the time it happens with, ahem, "oversubscribed" low-income clinics.

Also I have had Rx audited for high TDD of insulin such as the above. It definitely happens

 

[Sparda29]

Ah sliding scale insulin - nothing like trying to control sugars by reacting to what has already happened. SSI should not be used except maybe as a short term correction in addition to scheduled doses.

I have patients with variable Novolog dosing. Example, they are on 10 units AC TID, they'll add 2-4 units to the dose if they plan on eating more carbs that meal.

 

[WorthlessOxygen]

Also I have had Rx audited for high TDD of insulin such as the above. It definitely happens

I sat in on a couple audits with my DM where scripts like this were brought up but as long as we didn't fill early based off of max daily dose we were not penalized.

 

[PumpkinSmasher]

Ah sliding scale insulin - nothing like trying to control sugars by reacting to what has already happened. SSI should not be used except maybe as a short term correction in addition to scheduled doses.

I rarely use SSI but correction dosing is very useful for many patients especially those who do tend to fall off the healthy diet wagon off, have food insecurity or have a scale for carbs above a certain number per meal, etc

Flexibility in dosing is very important for many of my patients to be successfully managed

 

[owlegrad]

I think there might be a misunderstanding. Injecting on a "sliding scale" based on projected carb intake is good management. Injecting on a sliding scale based on how high the glucose level has already risen is less optimal. I am pretty sure that is what space cowgirl meant (although perhaps I should just let her speak for herself).

 

[BenJammin]

Ah sliding scale insulin - nothing like trying to control sugars by reacting to what has already happened. SSI should not be used except maybe as a short term correction in addition to scheduled doses.

WTF

 

[Sine Cura]

No one writes sliding scale regimens based on projected carb intake. In fact I have yet to see a single so-called sliding scale from anyone in my area.

 

[owlegrad]

No one writes sliding scale regimens based on projected carb intake. In fact I have yet to see a single so-called sliding scale from anyone in my area.

https://integrateddiabetes.com/Articles/insu/carb ratio article for mendosa.pdf

 

[confettiflyer]

No one writes sliding scale regimens based on projected carb intake. In fact I have yet to see a single so-called sliding scale from anyone in my area.

I see carb ratio orders all the time for projected use. Though less savvy patients will get a fixed dose + correction sliding scale based on preprandial BG.

But mostly these are insulin pump management patients and boluses are done via pump.

Actual order on the Rx itself is usually simplified due to label space for MDI pt’s for convenience. I’ve just been told “up to X units/day by sliding scale as directed” is sufficient to establish a max days supply.


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[deleted480308]

Ah sliding scale insulin - nothing like trying to control sugars by reacting to what has already happened. SSI should not be used except maybe as a short term correction in addition to scheduled doses.

A good use of SDI is for the patient with inconsistents diets or lack of ability/will to calculate carbs....which is almost every single patient

 

[BidingMyTime]

No one writes sliding scale regimens based on projected carb intake. In fact I have yet to see a single so-called sliding scale from anyone in my area.

I see sliding scale regimens, often for insulin pumps, all the time based on projected carb intake. The ones I see, are always for younger patients (<65 years), I don't think I've seen one for an older patient.

 

[deleted950169]

I've seen carb counting scales in both the young and the elderly. I generally dislike all sliding scales, a regular fixed dose so long as the patient isn't skipping meals is much easier for a patient to adhere to. But some patients swear by it and know how to self adjust and can guess their sugars etc

 

[Sine Cura]

This must be a regional thing or specific to work environment. The few times I cared to press about what "sliding scale" actually meant when I didn't get a TDD it was actually chasing numbers.

 

[confettiflyer]

This must be a regional thing or specific to work environment. The few times I cared to press about what "sliding scale" actually meant when I didn't get a TDD it was actually chasing numbers.

I hope that's not a regional thing, carb ratio dosing is standard of care IMO. I mean, unless you're eating MRE Pizza every night and can stick to a fixed dose 🤣

 

[spacecowgirl]

I think there might be a misunderstanding. Injecting on a "sliding scale" based on projected carb intake is good management. Injecting on a sliding scale based on how high the glucose level has already risen is less optimal. I am pretty sure that is what space cowgirl meant (although perhaps I should just let her speak for herself).

Correct. This is what I meant. Although most of the patients I ever worked with were notoriously bad at carb counting so I would say SSI with correction for meals probably isn't so great either.

 

[Curiousone1111]

Thanks everyone!

 

[Dred Pirate]

I have patients with variable Novolog dosing. Example, they are on 10 units AC TID, they'll add 2-4 units to the dose if they plan on eating more carbs that meal.

that is different than true SSI thou - nothing wrong with carb counting, that is how you are supposed to dose, but SSI based on a BG is reactionary and bad medicine