H&P prior to procedures. What's your work flow?

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wscott

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Hi,

In my new location and state, the ASC requires me to have a "comprehensive H&P" on record within 30days of doing all procedures. In most cases, this is not an issue, we do the procedure within 30 days of the H&P.

The issue is for procedures like SIJ injections that utilize steroid. Often times a patient has excellent relief for the duration of the anesthetic, but only partial relief with the steroid. I am used to scheduling them for a second procedure two weeks after the first injection routinely, without an office f/u in between.

The time frame when the second SIJ injection is scheduled can run over the alotted 30days since the last H&P. In my new environment, new to practicing in an ASC, and new to the state of Maine, if I go over the 30 day mark, it's required of me to do a new "comprehensive H&P", according to the ASC's citation of the medicare guidelines.

Do you practice with such a requirement? How do you fulfill the requirement to have an H&P within 30days for procedures? What is your standard? Assume it’s for a procedure that only uses local.

Thanks,
 
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Hi,

In my new location and state, for the ASC, it is required to have a "comprehensive H&P" on the record within 30days of doing all procedures. In most cases, this is not an issue. Patients get in for their procedure within 30 days, it's a one- time procedure and they f/u in clinic afterwards. For MBBx2 we can get the two in without a problem either because they can be scheduled back to back.

The issue is for procedures like SIJ. Often times a patient has excellent relief for the duration of the anesthetic, but only partial relief with the steroid, so we schedule them after the first injection routinely then f/u in 2 weeks to repeat the procedure one time, without an office f/u in between. This time frame for the second SIJ injection can run-over the 30days since the previous H&P, and now I have to do a new "comprehensive H&P" according the ASC and Medicare guidelines.

Previously, in my prior hospital based practice, it was acceptable by their standards to check off a form stating, "There are no significant changes to the patient’s history. It remains appropriate to proceed with performing the scheduled procedure", something like that.

What do you do in your office to fulfill the requirement in such situations? What is your standard? Assume it’s for a procedure that only uses local.

Doing a new "comprehensive H&P" in the ASC on procedure days would significantly slow down the flow.

Thanks,

your ASC rules are stupid. makes sense for bigtime surgeries. doesnt make sense for our line of work. is this a state reg. or just one for your ASC. might wanna talk to the administrators. i never had to deal with this when i spent time at an ASC
 
your ASC rules are stupid. makes sense for bigtime surgeries. doesnt make sense for our line of work. is this a state reg. or just one for your ASC. might wanna talk to the administrators. i never had to deal with this when i spent time at an ASC

I agree.

This is the administrators understanding of the medicare requirements for the state of Maine, and applies to all procedures or surgeries performed at the ASC.

Is this the sentiment of other readers? Is there anybody else operating with this requirement? Any ideas on how to manage a solution?

Thanks for the help.
 
Actually this is a new federal requirement for centers accepting medicare. They must have a complete H&P within 30 days, and you cannot do a procedure on the same day unless there is an emergency. The patient must have 1 day at least to read their bill of rights, center ownership etc.
 
Same thing applies at the hospital. I send the office notes and hospital forms over and then I check the update box. Sounds like your asc admin needs to ask around.
 
we experience this also. My H/p at the hospital is a form that is crap that i can scribble in 5 seconds if my office H and P is expired. We have to do an "interval note" which is a 5 second check box. It is annoying i agree. if you can dictate, jsut dictate off of your HandP...

Hi,

In my new location and state, the ASC requires me to have a "comprehensive H&P" on record within 30days of doing all procedures. In most cases, this is not an issue, we do the procedure within 30 days of the H&P.

The issue is for procedures like SIJ injections that utilize steroid. Often times a patient has excellent relief for the duration of the anesthetic, but only partial relief with the steroid. I am used to scheduling them for a second procedure two weeks after the first injection routinely, without an office f/u in between.

The time frame when the second SIJ injection is scheduled can run over the alotted 30days since the last H&P. In my new environment, new to practicing in an ASC, and new to the state of Maine, if I go over the 30 day mark, it's required of me to do a new "comprehensive H&P", according to the ASC's citation of the medicare guidelines.

Do you practice with such a requirement? How do you fulfill the requirement to have an H&P within 30days for procedures? What is your standard? Assume it’s for a procedure that only uses local.

Thanks,
 
We have EMR and it takes 5-10 secs to go through the template. Without the template the requirements are
procedure:
symptom:
heart/lung exam:
Airway:
ASA:

That's it.
 
With my EMR, it is a template and easy. My nurse does it for each pt at ASC and hospital.
 
why are you doing a 2nd injection 2 weeks later? and you are used to scheduling a 2nd injection routinely without a f/u in between...

maybe that is your problem to begin with?
 
why are you doing a 2nd injection 2 weeks later? and you are used to scheduling a 2nd injection routinely without a f/u in between...

maybe that is your problem to begin with?

Zinger.

Ferrari's ain't cheap.

Seriously, I need more Hooker's and Cocaine.

1st injection is for the patient.
2nd is for the hookers.
3rd is for the cocaine.

Does this count as a publication?

TO the OP: just screwing with you. We as a forum have a strong disdain for series of 3 type care.
 
Am J Phys Med Rehabil. 2001 Jun;80(6):425-32. Fluoroscopically guided therapeutic sacroiliac joint injections for sacroiliac joint syndrome. Slipman CW, Lipetz JS, Plastaras CT, Jackson HB, Vresilovic EJ, Lenrow DA, Braverman DL. The Penn Spine Center, Department of Rehabilitation Medicine, Philadelphia

"At 1 month, 5/6 sacroiliac joints injected with corticosteroid
described a relief of > 70%, in comparison to 0/7 of the placebo group (P < 0.05)."

"The average number of injections was 2.1"

A small study, but well designed.

So, for SIJ's I do the initial injection and schedule the second injection 2 weeks later. Why two weeks? It's enough time for the steroid to work and enough time for the patient to evaluate the effect on function.

At the time of their first injection, I give these clear instructions to the patient.

1) If you receive <80% relief during the first 2 hours after the first SIJ injection, then the SIJ is unlikely to be a major contributor to your pain. Then there is no need to repeat the procedure, and we will cancel the second procedure and have them return for an office visit to re-evaluate.

2) If your pain is completely gone, or lowered sufficiently for you to accomplish your ADL's comfortably. Then call us up two days before the second procedure is scheduled and cancel the second procedure because obviously, no need to repeat the procedure if the patient is feeling better.

Otherwise, we will do a second procedure in 2weeks, as the patient may derive added benefit based on literature cited in the Slipman study.

This approach helps expedite treatment for the patient. It is based on the literature. It also saves time, and a copay for the patient by avoiding a f/u visit in between, when considering the above study, the average number of patients would benefit from 2 injections within one month. The rationale for this approach puts only the patients' interest first.


Steve, I've been a member of this forum since 2003. I am well aware of "the forum having a strong disdain for series of 3 type care" and I fully support this sentiment. I have a sense of humor. But for you to assume a members intentions in their professional practice are unlawful or even irrational, even in jest, is not cool.

You kind of get to know someone after following the forum for a few years, and I like your treatment approach and greatly appreciate your efforts to counter the "series of 3 care" crap. So, I'll let your cheap shot pass. Keep up the good work.🙂
 
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Am J Phys Med Rehabil. 2001 Jun;80(6):425-32. Fluoroscopically guided therapeutic sacroiliac joint injections for sacroiliac joint syndrome. Slipman CW, Lipetz JS, Plastaras CT, Jackson HB, Vresilovic EJ, Lenrow DA, Braverman DL. The Penn Spine Center, Department of Rehabilitation Medicine, Philadelphia

"At 1 month, 5/6 sacroiliac joints injected with corticosteroid
described a relief of > 70%, in comparison to 0/7 of the placebo group (P < 0.05)."

"The average number of injections was 2.1"

A small study, but well designed.

So, for SIJ's I do the initial injection and schedule the second injection 2 weeks later. Why two weeks? It's enough time for the steroid to work and enough time for the patient to evaluate the effect on function.

At the time of their first injection, I give these clear instructions to the patient.

1) If you receive <80% relief during the first 2 hours after the first SIJ injection, then the SIJ is unlikely to be a major contributor to your pain. Then there is no need to repeat the procedure, and we will cancel the second procedure and have them return for an office visit to re-evaluate.

2) If your pain is completely gone, or lowered sufficiently for you to accomplish your ADL's comfortably. Then call us up two days before the second procedure is scheduled and cancel the second procedure because obviously, no need to repeat the procedure if the patient is feeling better.

Otherwise, we will do a second procedure in 2weeks, as the patient may derive added benefit based on literature cited in the Slipman study.

This approach helps expedite treatment for the patient. It is based on the literature. It also saves time, and a copay for the patient by avoiding a f/u visit in between, when considering the above study, the average number of patients would benefit from 2 injections within one month. The rationale for this approach puts only the patients’ interest first.


Steve, I've been a member of this forum since 2003. I am well aware of "the forum having a strong disdain for series of 3 type care" and I fully support this sentiment. I have a sense of humor. But for you to assume a members intentions in their professional practice are unlawful or even irrational, even in jest, is not cool.

You kind of get to know someone after following the forum for a few years, and I like your treatment approach and greatly appreciate your efforts to counter the "series of 3 care" crap. So, I'll let your cheap shot pass. Keep up the good work.🙂

I know you've been around and added the "just screwing with you comment" to let you know I know. It was for the jackhole needle monkey's who troll.

And if Slipman did it, I would call it suspect as well. Just ask the former fellows. I avoided the interview because of what I heard.
 
Am J Phys Med Rehabil. 2001 Jun;80(6):425-32. Fluoroscopically guided therapeutic sacroiliac joint injections for sacroiliac joint syndrome. Slipman CW, Lipetz JS, Plastaras CT, Jackson HB, Vresilovic EJ, Lenrow DA, Braverman DL. The Penn Spine Center, Department of Rehabilitation Medicine, Philadelphia

"At 1 month, 5/6 sacroiliac joints injected with corticosteroid
described a relief of > 70%, in comparison to 0/7 of the placebo group (P < 0.05)."

"The average number of injections was 2.1"

A small study, but well designed.

So, for SIJ's I do the initial injection and schedule the second injection 2 weeks later. Why two weeks? It's enough time for the steroid to work and enough time for the patient to evaluate the effect on function.

At the time of their first injection, I give these clear instructions to the patient.

1) If you receive <80% relief during the first 2 hours after the first SIJ injection, then the SIJ is unlikely to be a major contributor to your pain. Then there is no need to repeat the procedure, and we will cancel the second procedure and have them return for an office visit to re-evaluate.

2) If your pain is completely gone, or lowered sufficiently for you to accomplish your ADL's comfortably. Then call us up two days before the second procedure is scheduled and cancel the second procedure because obviously, no need to repeat the procedure if the patient is feeling better.

Otherwise, we will do a second procedure in 2weeks, as the patient may derive added benefit based on literature cited in the Slipman study.

This approach helps expedite treatment for the patient. It is based on the literature. It also saves time, and a copay for the patient by avoiding a f/u visit in between, when considering the above study, the average number of patients would benefit from 2 injections within one month. The rationale for this approach puts only the patients’ interest first.


Steve, I've been a member of this forum since 2003. I am well aware of "the forum having a strong disdain for series of 3 type care" and I fully support this sentiment. I have a sense of humor. But for you to assume a members intentions in their professional practice are unlawful or even irrational, even in jest, is not cool.

You kind of get to know someone after following the forum for a few years, and I like your treatment approach and greatly appreciate your efforts to counter the "series of 3 care" crap. So, I'll let your cheap shot pass. Keep up the good work.🙂

i think your protocol is good for the SI joint. I have no problems with it
 
still not making sense

1) if the patient gets <80% relief then no repeat SI joint
2) if the patient gets >80% (improved ADLs)-100% then no repeat SI joint

why even bother repeating the SI joint (citing a suspect study doesn't help - but it is better than nothing)?
 
still not making sense

1) if the patient gets <80% relief then no repeat SI joint
2) if the patient gets >80% (improved ADLs)-100% then no repeat SI joint

why even bother repeating the SI joint (citing a suspect study doesn't help - but it is better than nothing)?

I'll support him. I think he was saying if you do get >80% relief but it doesn't last up until 2 days before the next scheduled procedure he'll repeat it, otherwise live and let live. I think that's good logic, no?
 
still not making sense

1) if the patient gets <80% relief then no repeat SI joint
2) if the patient gets >80% (improved ADLs)-100% then no repeat SI joint

why even bother repeating the SI joint (citing a suspect study doesn't help - but it is better than nothing)?

There is not a finite line between <80% and >80%. If it's close, I let the patient make the decision lead by functional outcome from the first injection.

The study I quoted was one of several quoted in the ISIS guidlines.

The study comes from a well experienced, respected University based, academic fellowship. Is was also reviewed by the American Journal of Physical Medicine and Rehabilitation and ISIS, and found to be credible and valuable enough to publish. Not sure, about your reference to the study being "suspect".

You have to hang your hat on something.

Glad to see others agree with the algorhythm.
 
wscott - you are not making much sense

first you state that you schedule all of your SI joint injections as a series of 2 (you mentioned "routinely without a f/u").

then you use a study (which can be read here http://www.kalindra.com/SI Medical Files/slipman_fluro.pdf) to support your argument for a series of 2 - this study recommends:

Those patients receiving therapeutic injections were scheduled for two in a 2-wk
interval, and the second was canceled if the initial injection resulted in 90% symptom relief. Patients were then reevaluated. If a steroid effect was not realized, no further injections were scheduled. A steroid effect was defined as a minimum of 50% symptom reduction of at least 1-day duration within a 7-day period after the therapeutic injection. If the patient experienced progressive but <90% relief, an additional injection was scheduled. No patient was administered more than four injections.

I would argue that the above recommendations sound a bit "Overboard" - and furthermore, they only did the above if the patient had a documented response to diagnostic local anesthetic only block with intra-articular confirmation by contrast administration.

So these patients would get a diagnostic block, and then a series of 2 therapeutic steroid injections into the SI joint, all within a few weeks...

come on...

how come, most of us, when it is true SI joint arthropathy can get away with one SI joint injection 2 to 3 times per year?

I remember talking to a guy who does a series of 3 for any type of injection, and his argument was "you don't take just one motrin for the pain, you keep on taking motrin after motrin to calm down the inflammation"... my counter-point: "How much steroid are you willing to inject into somebody before you are convinced you have calmed down the inflammation"... do we really need 80-120mg of Kenalog in an SI joint?

by the way, I don't respect Slipman...
 
this is an interesting debate on the difference b/w diagnostic and therapeutic injections.

if all you are doing is diagnosing, then perhaps 1 injection and then RFA is the way to go.

if you are doing the injections for therapeutic reasons. Then why wouldnt the motrin analogy be applicable. One can deposit steroids to calm things down. However, the SI joint is a very mechanically used joint. No matter how much steroids one uses, if one is constantly active, the inflammation can flare back up. If the patient is getting >50-80% (or whtever your metrics are) and is utilizing less opioids/meds and steroid side effects are not a concern or are mitigated, then what's the downside in properly trained hands? It is a relatively safe procedure.
 
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