H&P before procedure?

[radic]

I have a question. As long as I've been practicing, I always will evaluate a patient in my office prior to scheduling them for a procedure in the hospital. There is this Ortho doc in my hospital that refuses to send me his epidurals (he has a huge volume) because I refuse just do the epidural without doing an eval on the patient. He has been telling other docs that I do the H&P before the procedure simple to "double bill" (although I get paid salary). So he sends his epidurals to another group who will do them no questiones asked. The other group has left the hospital and now he is raising hell that I won't simply do the epidurals at his demand. I've explained to him (very nicely) that I need to make sure that the patient is not on any blood thinners, the procedure is appropriate, etc. He says that that's his job. Moreover, it just seems smart for me to document something like a foot drop or something BEFORE the procedure so I can prove I had nothing to do with it.

My question is...is it fraud to do a procedure without a documented H&P. The higher powers in the hospital are putting pressure on me to just do the epidurals and I'm not budging (the other group was doing epidurals on patients on Plavix). I need something to show them that someone (Medicare or anyone) requires an H&P in the chart from the physician prior to doing the procedure. Can anyone help me out? Thanks!

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[Jcm800]

I have a question. As long as I've been practicing, I always will evaluate a patient in my office prior to scheduling them for a procedure in the hospital. There is this Ortho doc in my hospital that refuses to send me his epidurals (he has a huge volume) because I refuse just do the epidural without doing an eval on the patient. He has been telling other docs that I do the H&P before the procedure simple to "double bill" (although I get paid salary). So he sends his epidurals to another group who will do them no questiones asked. The other group has left the hospital and now he is raising hell that I won't simply do the epidurals at his demand. I've explained to him (very nicely) that I need to make sure that the patient is not on any blood thinners, the procedure is appropriate, etc. He says that that's his job. Moreover, it just seems smart for me to document something like a foot drop or something BEFORE the procedure so I can prove I had nothing to do with it.

My question is...is it fraud to do a procedure without a documented H&P. The higher powers in the hospital are putting pressure on me to just do the epidurals and I'm not budging (the other group was doing epidurals on patients on Plavix). I need something to show them that someone (Medicare or anyone) requires an H&P in the chart from the physician prior to doing the procedure. Can anyone help me out? Thanks!

there is no requirement for an H and P, if you are only billing for the procedure. But common sense would tell you it is better to see the patient first, which what you are doing. I think you are doing the right thing. Even if he is doing "his job" if something gets missed, whose ass in on the line, yours! You could do it like old school kinda, see them in the holding area, tell them to bring all the paperwork you could meet them, and if appropriate leave time for them at the end of the day or something, and if not appropriate re-schedule them... But, IMHO, you are one doing the procedure, your license, your ass on the line, ou should practice however you feel comfortable and is the safest thing.

eff that guy. i know its easy for me to say... but eff him.

if they bring up the "double billing thing" tell the hospital the surgeon should jus do the surgery, why does he need to see the patient...

or better yet, make a deal with him, you will do the scheduled "epidural" he wants without an eval, if you send him an L5-S1 discectomy that he does without seeing the patient...

 

[PMR 4 MSK]

You are basically dealing with a surgeon with either a lack of respect for pain medicine, or ignorance. You can always schedule his pts for injection, do a pertinent H&P for your peace of mind and medico-legal documentation prior to the injection, and let the hospital worry about billing it (what does he care how you bill it anyway?).

I get a lot of joint injections from my ortho partners to be done under fluoro - mainly shoulders and hips. Some are diagnostic, others therapeutic, often both. I review the chart and Hx, ask questions I need to know, do an exam and discuss the injection with the patient, if I feel it is appropriate. Some have tried sending pts for epidurals the same way, but stop when they realize my policy is this - If they want me to do the injection, and then they are going to do the follow-up for further care, I'll do the injection. If it's for me to do further care, I want a new pt eval first in the clinic, or at a minimum, at the ASC or hospital. So I don't take orders for "LESI and f/u management." I'll make the call.

The trouble you may be having is being utilized as his (the orthopod's) diagnostic or therapeutic tool, when you are used to having pts referred for eval and treat at your discretion. You may feel like his "lackey."I personally like getting diagnostic injections to do - no or minimal follow-up (only if they have a problem), availablity for future consult, and it keeps the referral patterns going.

Whether or not the injections are "appropriate" is often a matter of opinion. I sometimes find pts referred to me for "possible epidural" who would better be served by facet jt injection, PT or meds, or whatever. More foten, though, the ESI is a reasonable approach. But if the referring doc wants just a diagnostic SNRB or a therapeutic TFESI, and I don't consider it either contraindicated or unreasnable, and the referring doc will do the follow-up, I'll do it. It pays the bills (often quite well), and I have less pts in clinic bogging me down.

 

[Tenesma]

1) since you are doing procedures in the hospital - medicare and JACHO have rules and regulations stating that any procedure (including endoscopies) require at least an abbreviated H&P (current within 30 days) and updated within 7 days (usually there is no change).... so technically the hospital is braking rules by pressuring you to do this....

2) now you could come to a compromise and generate a quick easy H&P with a checklist --- that way you can still bill for an E/M if you'd like but would cover all the PERTINENT issues: medications, anti-coagulants, recent infections, concurrent antibiotics, blood disorders, INCLUDING a quick Neuro Exam.... and go ahead w/ the procedure - that way you make hospital happy, and you get to do a TON of easy no-headache procedures without inheriting the patient --- even though I would recommend handing all of the patients (

 

[Tenesma]

even though i would recommend handing all of the patients (at least those you are interested in keeping) a brochure about yourself, your other services and your contact information -- and in each H&P/Procedure note (cc:ed to the orthopedic surgeon) a comment stating that if the pain does not respond to intervention that you would suggest a full Pain Medicine Consultation

3) or tell him to screw off and have Interventional Radiology be his waterboy...

 

[PAINBILLER]

I'm sure your malpractice carrier would want you to get a basic H&P before proceeding with your procedures as well. You may want to contact them to provide you with their guidelines on this issue. Just a thought.

 

[SSdoc33]

or better yet, make a deal with him, you will do the scheduled "epidural" he wants without an eval, if you send him an L5-S1 discectomy that he does without seeing the patient...

careful...... he'd probably do it......

he IS a jackass, but clearly you dont want to lose the referral source. id try to make nice if it has a bearing on your volume and reimbursements. if not, then he can eat it.

but the whole idea of "double-billing" is wrong. you are not "double billing". you are a separate specialty performing a different service than what the orthopod offers. why does he care if the insurance gets billed twice -- which is allowed and good medical practice, by the way --? my guess is that this is a bit of a pissing contest and he doesnt you want to make any decisions in the care of "his" patients, and is using this double billing issue as an excuse.

 

[Jcm800]

there is no requirement for an H and P, if you are only billing for the procedure. But common sense would tell you it is better to see the patient first, which what you are doing. I think you are doing the right thing. Even if he is doing "his job" if something gets missed, whose ass in on the line, yours! You could do it like old school kinda, see them in the holding area, tell them to bring all the paperwork you could meet them, and if appropriate leave time for them at the end of the day or something, and if not appropriate re-schedule them... But, IMHO, you are one doing the procedure, your license, your ass on the line, ou should practice however you feel comfortable and is the safest thing.


let me clarify, there is no requirement for an H and P, in the form of a consult prior to the procedure. The hospital likely requires a quick pre-op H/P, but this is not what i meant. What i meant was that you can do this quick pre-op H and P, to get the info you want...

 

[Aether2000]

With patient assessment forms being complete and if there is a MRI available, a confirmatory H and P can be done briefly before the procedure and simply don't charge for it. You can develop a rapport with the pompous arrogant orthopedist over time and develop a recurring revenue stream. Consider setting up your own office outside the hospital for procedures ...

 

[PMR 4 MSK]

Order/request today from a hip orthopod - "Right hip injection under fluoro, LESI with emphasis on L5 facet."

Huh?

This is why you do your own consults and determine what to do. I understand he wants the hip ruled in or out, but let's get the terminology correct. I'll be intersted to find out what he's really requesting.

 

[Tenesma]

this is where picking up the phone and speaking with the orthopod can be of great value because you can flex your knowledge and demonstrate exactly how much you know about diagnostic procedures --- hopefully, he will be impressed enough to realize his own shortcomings and change future referrals to "Please eval right buttock pain, hip vs spine source"

 

[Jcm800]

this is where picking up the phone and speaking with the orthopod can be of great value because you can flex your knowledge and demonstrate exactly how much you know about diagnostic procedures --- hopefully, he will be impressed enough to realize his own shortcomings and change future referrals to "Please eval right buttock pain, hip vs spine source"

look man, let him do "his job!"


I once had a general ortho, old timer, consult me for eval and treat for LBP. I asked him kind of joking why do they waste your time with this stuff. He looks at me, serious as a heart attack and says "who else is going to make the diagnosis of low back pain?"

i didnt quite understand this, but it has been a running joke around here for many moons. If i hadnt been so confused with his statement I could have asked him if he really thought low back pain was a diagnosis of any value...maybe he uses the diagnosis "lumbago"

 

[Tenesma]

i have to correct an earlier statement - medicare and JCAHO require H&P for procedures where sedation or anesthesia will take place, so if your procedure doesn't involve sedation then the requirements are less.

 

[PainMD23]

Can you bill for E&M if the procedure takes place on the same day? I know we've been through this before in a few other threads. WHat does everyone else do? If I get a referral from an ortho or NS for a specific injection they are often scheduled for a procedure day without me having performed the H&P. I have a pre-op H&P form with check-boxes, perform a PE, review imaging, etc, on the day of procedure. Often I agree with the referring surgeon, sometimes not. I don't bill for E&M, only for the procedure (although I have plenty of documentation and an H&P on the chart). Is there any way to bill for the H&P if it is documented? Are there rules re: ASC, hospital, office etc regarding payment for H&P and procedure on same day?

 

[PMR 4 MSK]

Can you bill for E&M if the procedure takes place on the same day? I know we've been through this before in a few other threads. WHat does everyone else do? If I get a referral from an ortho or NS for a specific injection they are often scheduled for a procedure day without me having performed the H&P. I have a pre-op H&P form with check-boxes, perform a PE, review imaging, etc, on the day of procedure. Often I agree with the referring surgeon, sometimes not. I don't bill for E&M, only for the procedure (although I have plenty of documentation and an H&P on the chart). Is there any way to bill for the H&P if it is documented? Are there rules re: ASC, hospital, office etc regarding payment for H&P and procedure on same day?

By Medicare rules, you can only bill E&M if it is for a seperately identifiable problem than the procedure you are going to perform, otherwise the H&P is considered an intergral part of the procedure, and may not be billed seperately. PRivate insurance companies may have different rules, and you can try to bill them for E&M.

I personally think it's not appropriate in most settings. The H&P you are doing is problem-pertinent, unless you are going to tak over care of the patient from that point for that problem, in which case, you should have done a consult prior, unless extenuating circumstances prevent it. Also, many insurance companies, might not accept E&M codes at ASC's or other sites of service.

 

[Tenesma]

this is exactly the reason why I do NOT do procedures and consults on the same day --- why do work and not get compensated for it - and i get a better feel for the patient, establish a relationship and the patients are fine w/ that system.

 

[SSdoc33]

By Medicare rules, you can only bill E&M if it is for a seperately identifiable problem than the procedure you are going to perform, otherwise the H&P is considered an intergral part of the procedure, and may not be billed seperately. PRivate insurance companies may have different rules, and you can try to bill them for E&M.

I personally think it's not appropriate in most settings. The H&P you are doing is problem-pertinent, unless you are going to tak over care of the patient from that point for that problem, in which case, you should have done a consult prior, unless extenuating circumstances prevent it. Also, many insurance companies, might not accept E&M codes at ASC's or other sites of service.

AAAAARRRRRGGGGHHHH!!!!! i thought that was modifier 25!!!!!

my belief is that you CAN bill both on the same day. btw, have i mentioned how seamlessy perfect our medical system is? like awell-oiled machine, i tell ya.........

 

[Jcm800]

this is exactly the reason why I do NOT do procedures and consults on the same day --- why do work and not get compensated for it - and i get a better feel for the patient, establish a relationship and the patients are fine w/ that system.

this is our policy also. We tell all patients it is a consult only on the visit visit. A few times a year i bend this rule, for a young person with a huge disc and terrible pain, or someone that drives 4 hours to see me. But its rare...

we have debated this E/M and procedure thing on the same day countless times...


to my knowledge, you can bill 99243(4-5) the same day as procedure, but they will cut the payment on the E/M. The 25 modifier would not apply in this case, unless the E/M is for a different problem then what you do the procedure for. Perhaps you evaluate the neck pain, then do a lumbar procedure, maybe Mod 25 is applicable. But also to my knowledge, the 25 mod is highly abused and misused and is a red flag...

so be carefull. I often use the arguement, I dont care if its a red flag if im using it for the right reason, let them audit me... but i have changed my opinion to, its just not worth it...

 

[Tenesma]

i know a LOT of pain docs that do the "H&P" in the fluoro room - cursory glance at the MRI (which MOST pain docs don't know how to read anyway and rely far too heavily on often erroneous rad reports) - do the injection...

surgeons love it because they end up getting what they want ---

patients love it if there is relief --- they hate it when the relief isn't there, and they are then fused, and then come back to you because of persistent back pain, and it turns out it was SI joint pain all along...

I really can't understand how using the above mentioned modus operandi (ie: consult/injection on same day), is in any way truly efficient... Because you have to figure there are going to be patients who have stories you aren't ready for, patients you are going to cancel or potentially want to change the injection, etc...

I'd like to hear from those practitioners who do things on the same day, what the advantages are.... I am excluding patients who have driven 4 hours to see you or patients who are rolling on the floor in pain.

 

[lovebailey2001]

I also faced the same problem with my ortho colleagues, who used to send patients for injections to me as if they are sending them to a pathologist or radiologist for some invesigation! but i want to feel like a 'Pain physician', so I refused to go by their way and told them clearly that the time n type of injection will be decided by me, only after eval of pt. result they almost stopped sending their patients and have started doing caudals n TFESI by themselves! By Gods grace now I am getting my patients by word of mouth and their failures.
By the way I am in a govt. run setup n at my place 'Pain Medicine' is relatively new n free for all field!

 

[Mister Mxyzptlk]

With patient assessment forms being complete and if there is a MRI available, a confirmatory H and P can be done briefly before the procedure and simply don't charge for it.

This is what I do.