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   RE: office INRs
 From: Craig Ross
 To: Member Forum
 Posted: 11-27-2017 16:08
 Message: Michael S,

Excellent post.  Thank you.  LOVE the process, the thought behind it, and the billing.  I think the point about the MA telling you the result and you acting on it (increase/decrease/no change coumadin, when next) justifies the 99211.  Without it, you are just doing a test and I don't believe you can bill the 99211.

Cheers,
Craig

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Craig Ross, M.D.
Family Medicine
South Arbor Family Care
Ann Arbor, MI
M: 734-756-8446
W: 734-707-7075
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Original Message:
Sent: 11-02-2017 15:59
From: Michael Safran
Subject: office INRs

Rant #1 - We all do so many things in office that a malpractice lawyer can argue why didn't you refer patient to specialist.

Sorry if this is a long post.   I have always been a big proponent of doing INRs.   Doing them for at least 15 years.  Reasons are multiple.......
1) The bonus of not having to handle abnormal results via phone, late night phone calls from national labs (which always seem to be on Friday nights) is priceless!!
2) I think I do a better job then coumadin clinic and I believe the ability to track levels more closely has dramatically lowered my patients hospitalization rates.  So easy to bring patient back in a week if started on new drug that can affect level, etc.

Rant #2 - The Urgent Care clinics frequently do not take coumadin dosage into consideration when prescribing an antibiotic.  Cipro is the biggest one that seems to affect the INR.    https://www.ncbi.nlm.nih.gov/pubmed/24657899

3) Patients can come in the day before procedure / surgery and check if INR is now low enough to go ahead.
3a) At other end, after the proceedure, it is now so easy to advise patient when INR is therapeutic and they can stop Lovenox bridging.
4) I can more easily track if patients are not doing their INRs monthly (if they miss appts. etc.)
5)  When office testing first started, I believe machine was free - I just had to commit to purchasing 2 or 5 boxes (cant recall) over a year or two.
6) Very Important - Our patients are used to addressing many things when they see us.   You will need to politely educate patients that this is a "nurse" INR visit and not a regular MD / NP visit.   If they have an issue they want to discuss with doctor advise that they call ahead and request to change INR visit to MD visit.   After 1 or 2 times, most patients will understand and cooperate.
7) I believe the INR machine improves outcomes by facilitating MD visits as well.   For example If patient has atrial fib with mildly increased ventricular rate or DVT, etc. very easy to say, "when you come in next week for your INR, I will check you and see if heart rate is now lowered or swelling is better", etc.

Billing
INRs are scheduled during regular office hours and performed by medical assistant. (not on my schedule)
We bill INR plus 36415.   The reimbursement for the INR barely covers cost.
We also bill 99211 if done by MA and in normal range and I dont see patient.   If I am with another patient, MA interrupts me for 10 seconds and I advise MA to tell patient to schedule next INR in a month.
If out of range, I will ask that patient wait and I will see to adjust coumadin dosage.  Or, if there is something I want to discuss....test result, check pulse rate, BP.... I ask for patient to wait if they can and I see patient between visits.  These are usually billed at 99212 or 99213.
If I am in between visits, I will discuss INR results with patient, even if normal.   At least 1/4 to 1/2 the time, something else comes up or needs discussion and that visit now becomes a 99213 or 99214.  ("Doc my arthritis is bothering me, I know I cant take advil, what should I take? etc.)

I believe it definitely helps my bottom line, and again, no after hours INR phone calls for abnormal results - priceless.
Sorry for long post.   Hope it is helpful.






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Michael S. MD
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Original Message:
Sent: 11-01-2017 17:27
From: Scott Turner
Subject: office INRs

We stopped doing INRs and managing Coumadin years ago when the Risk Management folks told us if you live in a community with a Coumadin Clinic you should refer your patients there. Their reasoning was if your patient has a bad outcome with bleeding or clotting (which they fully recognize can happen whether they are in or out of range) and you had a Coumadin Clinic available but were managing the medication yourself, you would be open to risk. So after 20 years of managing Coumadin in rural practice, I gave it up when I moved to a larger community. Of course I gave up C-sections, Streptokinase and colonoscopy too so comparatively it was easy to quit.

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Scott Turner
PatientCare Family Clinic
Springfield MO
4178320078

Original Message:
Sent: 10-31-2017 09:57
From: Jean Antonucci
Subject: office INRs

Thanks I also rec'd a nice email offlist
 Since the machine is free and there are 25 test strips that are good through 2019 I will use em up I guess

 A side rant is these coumadin clinics people  go to  I think this is another hospital racket that fragments care and that Fps buy into- oh we are so busy so  we cannot do our work we are too busy( to do our work) and it undercuts  us little by little A local hospital now has an osteoporosis clinic  We have wound clinics All stuff PCPs can do perfectly  well but they will cut off a hang nail then the  digit then the hand until PCPs ar e left with what? sore throats?  Starfiled  taught me this   You stop  doing it and eventually you are not allowed to do it .Why I once briefly worked in an office where people went to a coumadin clinic  but the PCPs wrote for the coumadin Can you imagine!!! Writing a script for a dangerous med whose  lab test s  you do not see or manage??

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Jean Antonucci

Original Message:
Sent: 10-30-2017 21:17
From: Kris Oaks
Subject: office INRs

So, you can bill the cpt for the actual INR test, not the venipuncture, and a 99211 if a nurse does it, I'm assuming a 99212 or 3 if a doctor does it. I agree with Kathy, it's about break even but you get an office visit out of it.

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Kris Oaks
Kristin L. Oaks D.O. Inc.
Worthington OH
614-216-7288

Original Message:
Sent: 10-27-2017 12:46
From: Jean Antonucci
Subject: office INRs

Hi I have never had enough  INRs  to make the machine etc worthwhile  but i was just given a machine and many    non expired test strips  I will look up the coding details but  wonder how many  any of you getpaid Do you  also do a visit because you a re telling them the results/ Normally  the results- telling either is unpaid or maybe gets added in to a 40.00   99490 if there is enough work for that  Thanks

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Jean Antonucci
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