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Nonphysiologic

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Hey guys, I wanted to know if any of you have been in this position before.

I’m going out of the country for two weeks. I’m the only one in my group to see this one particular insurance because of one the guys that works here who also is certified with the insurance had some pretty bad health issues recently.

What do I do about the patients that need refills?

Would it be unethical/ placing massive legal risk to provide a two week supply (not increasing at all) until I get back without even examining the patient?


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What? You wrote that question really poorly.

is it your patient? Why wouldn’t you see them before you leave and then after? You’re gone for 2 weeks not 2 months

If it’s not your patient, of course no meds Until they’re established and plan of care is documented. But you wrote refill like they’re a established regular, so I’m not sure the problem here?
 
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Do you see established pts weekly?

There are opiate pts in my practice that I see bimonthly in some cases.

Most are monthly. If I can't trust you for a month you get nothing from me.
 
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Well these patients aren't necessarily "my" patients. They are the groups patients. Depending on which doctor is available that day they will see. We see every single patient and perform an exam on opioid monthly no exception. We are extremely strict. Its not necessarily about not trusting the patient but its more about CYA in the current climate. UDS every three months no exception. They bring their pills in every visit for a pill count otherwise its considered a strike. If you forget your pills twice thats considered violation that they've signed. This might seem like a lot to many of you but honestly I know a lot of docs that have tried to do the right thing get investigated. Also, I've inherited a ton of patients from an older pain doc who was a little loose with his prescriptions to say the least so I am also in the process of cleaning things up.

So basically I saw some patients last month and they do come in for regularly scheduled monthly visits if they want their medications so I can document an exam and improved PEG score as well as increased ability to perform ADLS and address the 4A's. To be honest I thought this was universal? Im surprised people prescribe narcotics at all without monthly follow ups.

Anyways I guess my specific question would be would it be unethical to prescribe medications without seeing the patient just for a week? And YES I have seen these patients before. I wouldn't blindly prescribe any medications without having assessed the patient.
 
DEA allows 90 days on schedule 2. Sounds like your clinic is ripping off insurance and taking people’s money just to see them every month.

Unless you only treat high-risk patients who need to be seen every month. I don’t have the patience for that and if you are high risk I wouldn’t offer narcotics.
 
Well these patients aren't necessarily "my" patients. They are the groups patients. Depending on which doctor is available that day they will see. We see every single patient and perform an exam on opioid monthly no exception. We are extremely strict. Its not necessarily about not trusting the patient but its more about CYA in the current climate. UDS every three months no exception. They bring their pills in every visit for a pill count otherwise its considered a strike. If you forget your pills twice thats considered violation that they've signed. This might seem like a lot to many of you but honestly I know a lot of docs that have tried to do the right thing get investigated. Also, I've inherited a ton of patients from an older pain doc who was a little loose with his prescriptions to say the least so I am also in the process of cleaning things up.

So basically I saw some patients last month and they do come in for regularly scheduled monthly visits if they want their medications so I can document an exam and improved PEG score as well as increased ability to perform ADLS and address the 4A's. To be honest I thought this was universal? Im surprised people prescribe narcotics at all without monthly follow ups.

Anyways I guess my specific question would be would it be unethical to prescribe medications without seeing the patient just for a week? And YES I have seen these patients before. I wouldn't blindly prescribe any medications without having assessed the patient.

I would guess I see 65% of my opiate pts monthly, and the others every other month. I have 2 or 3 I do every 3 months.

This is actually something I've been thinking about recently bc I'm drowning in pts right now and I need to get new pts in that are waiting to help out my partners.

I need to go to Q3M for a lot of these pts. Quarterly urine is a law in Georgia, so there's that...That pill count thing forgetting to bring in the bottle seems a little crazy to me, but I understand why you do it. I very rarely do counts.

Edit - BTW, I'm not ripping off insurance companies...I'm just trying to stay on top of things.
 
way over the top. May be nice to bill 12 level 4 follow ups per opioid patient per year. But not necessary. If you’re that skeptical of your patients, just don’t write it.

2 month followup is fairly standard IMO. I don’t have a single pt coming every month for followup. That’s miserable. Life revolving around pain clinic appointments. Again, imo, if you can’t trust someone to space out to q2mo followup, Get them off opioids .Simple
 
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Level 4? My monthly opiate pts are all 99213.

I don't understand why a pt on stable opiates requires a level 4 visit.
 
You know what...Yall did it for me. I'm pushing these out from now on...What I'm doing is unnecessary.
 
I would guess I see 65% of my opiate pts monthly, and the others every other month. I have 2 or 3 I do every 3 months.

This is actually something I've been thinking about recently bc I'm drowning in pts right now and I need to get new pts in that are waiting to help out my partners.

I need to go to Q3M for a lot of these pts. Quarterly urine is a law in Georgia, so there's that...That pill count thing forgetting to bring in the bottle seems a little crazy to me, but I understand why you do it. I very rarely do counts.

Edit - BTW, I'm not ripping off insurance companies...I'm just trying to stay on top of things.
The q3mo UDS was written by a retiring pain doc. And yes, he owns a UDS company. No COI there. Phewy
 
You're not doing quarterly urine Steve?
 
Sorry to post so many times...

You're saying pts on chronic opiates are all 99214 follow ups bc the presence of COT makes them moderately complex?

Seriously? I'm leaving all that dough on the table?!?!
 
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You're not doing quarterly urine Steve?
Nope. Randomly. Some q6, some q12, some get a call to come in. Gave my nurse team the rulebook and they decide, making me not the bad guy and not aware of when so I cannot get accused of targeting by patients. I also have 10-20 patients I don’t check. They rotate on the palliative list and usually make one more visit.
 
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Sorry to post so many times...

You're saying pts on chronic opiates are all 99214 follow ups bc the presence of COT makes them moderately complex?

Seriously? I'm leaving all that dough on the table?!?!
Yes. My 3’s are getting no scheduled rx, no imaging, and no procedure ordered. Some are post procedure to tell me mbb worked and wore off. I walk out and no charge them. We have phones you know.
 
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They can still see your partners. They just need to pay cash. I have patients who lose their insurance or don’t have a valid PCP referral in between appointments and if it’s truly an “emergency” to them they need to self-pay.
 
99213 for me - Visit under 25 min.

99214 for me - Visit over 25 min. I rarely bill a level 4 follow up. Who knows how much money I'm missing out on...

I hate billing.
 
99213 for me - Visit under 25 min.

99214 for me - Visit over 25 min. I rarely bill a level 4 follow up. Who knows how much money I'm missing out on...

I hate billing.

You’re missing out on some money for sure. If you’re managing meds even if they’re chronic, looking at pdmp, assessing side effects etc etc it’s a level 4. New med or procedure ordered level 4. We actually just went through a billing update session with our hospital.

You’re probably doing more than you give yourself credit for because you’re used to doing these things and it comes naturally. Make sure your documentation meets the rules and bill accordingly.


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I need to invest time in learning this stuff. Who knows how much I'm under billing. Probably a lot.
 
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How do you write for 3 months of pills ? Most pharmacies don’t allow refills on norco/oxycodone scripts. I don’t like post dating scripts either and most our scripts are through Epic via the secure app. I can’t keep track of sending those in every month for patients I don’t see that month.
 
Handwritten Rx that say, "May fill after...xxx."

Date the Rx.
 
I need to invest time in learning this stuff. Who knows how much I'm under billing. Probably a lot.

there’s some helpful apps as well. I downloaded one back in the day called VisitCoding. It’s great. Plug in various scenarios and play with it. After a while it becomes second nature and you don’t think about it much.

It’s also a nice reminder that often you review an old X-ray/MRI, or review another physicians progress note, and that you should always document such to get credit for it, in case your medical complexity is hovering between 3 and 4.
 
Perfectly fine to do that

How else could you do it?
 
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That link says you can do multiple Rx
 
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Honestly monthly may seem excessive but I'm not taking any chances at all, especially if the vast majority of patients are ones that I inherited. As I build a relationship that may change but for now I'm assuming the worst and covering my a**. FWIW I almost never bill level 4. Always underbill.

Check this out:
ADDRESSING THE OPIOID EPIDEMIC WITH BALANCE . Its by this pain doctor/attorney MD.JD. He wrote a book called prescribe like a lawyer. He goes through a ton of case law of doctors getting introuble.

Just read through that, it'll scare you. Now I get it, there are a ton of pill mills and unethical doctors out there but it seems even docs trying to do the right thing are getting in trouble.
 
How do you write for 3 months of pills ? Most pharmacies don’t allow refills on norco/oxycodone scripts. I don’t like post dating scripts either and most our scripts are through Epic via the secure app. I can’t keep track of sending those in every month for patients I don’t see that month.
many states do not allow "do not fill until" or "fill after".

if you are going on vacation in the US, you can electronically still prescribe medications to their pharmacy from your laptop.

better yet, look forward on your schedule and see who you would see during these 2 weeks. on your last appointment with them prior to leaving, you can write for code D prescriptions: Type in "CODE D 2 month prescription" on to the prescription. some pharmacies wont take it if it is handwritten in. and of course change the amount...


my general rule - patients on >30 MED or > low risk of misuse I see every 6 weeks-2 months, and those <30 MED (ie tramadol) I see every 3 months. if I think I have to see them every month because of moderate or high risk of misuse, then a) they are put on butrans or b) they are never offered opioids.


fwiw, do not intentionally underbill. work on billing correctly. underbilling apparently can also be problematic. we think of the money we are not asking for and think it will put us under the radar, so to speak but it is still considered fraud...

 
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99213 for me - Visit under 25 min.

99214 for me - Visit over 25 min. I rarely bill a level 4 follow up. Who knows how much money I'm missing out on...

I hate billing.

a lot. dont be scared of the boogeyman, and dont leave money on the table. blue cross and medicare wont bat an eyeless and 20-30K/year, but you may.....
 
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