Re: cerumen removal

January 14, 2010

BCBS here pays about $50 for cerumen removal. Wholefoods sells ear candles that would work well for most people, though may be hard for the elderly to manage this DIY .HelenTo: From: dr_levin@...Date: Wed, 13 Jan 2010 18:49:00 -0500Subject: Re: , please help to check the billing/coding rules

Bill as ear pain, don't bill removal earwax at all -- E & M pays better

Re: [Practiceimprovemen t1] Re: PQRI

thanks I am working my way up to this . I remember Gordon tried to introduce the first IMPs to doc Site. Does doc site provide Valium? Will you need extra visits with RAmona when I complain? AH this could be good for Ramona if I do PQRI!Jean

On Tue, Jan 12, 2010 at 8:50 AM, Haughton MD, MS <jhaughtondocsite (DOT) com> wrote:

is right – it appears that PQRI (and its ability to report structured clinical data – either directly or as numerator / denominator info is a key part of health reform / payment reform – paying based on quality, cost [ risk adjusted expected vs observed gainsharing on top of fee for service? ] and patient satisfaction – which should put the IMP practices in good stead (vs current system of paying fully for volume of service).

Regarding my offer for PQRI @ $250 a user and trust and is it worth it:

1) Ramona Seidel is my physician

2) I’ve been working with Gordon and others for about a dozen years, trying to make scalable quality healthcare a reality

3) Some IMPs have used docSite’s old system – its registry (which is a core, core part of our current and ongoing offering that can augment an EMR/ EHR or act as an EMR/EHR for meaningful use payments)

Regarding is PQRI worth it – If you don’t have about $50,000 of medicare billing, it really may not be worth the hassle. BUT, whether through AAFP (for Diabetes) or DocSite (for prevention or diabetes or other) or another program (there are about 70 options out there this year) --- it should take about 2 or 3 hours to accomplish the activities associated with collecting, and submitting data on 30 consecutive patients. In 2008, we had many primary care physicians who received as much as a few thousand $. Many received $800-$1500. Some surgeons received as much as $15K or $20K.

In short if you are doing Diabetes – use the AAFP site. If you are doing prevention and want to use a system run by a physician who cares about quality, feel free to use the discount code I put in the last e-mail ThankYou08 to make the cost $250 instead of $350.

Thanks –

Haughton MD, MSChair / CMO

office:

mobile:

fax:

Raleigh | polis

www.docsite. com

Don’t miss the opportunity to earn a bonus payment of up to 2% of your total allowed Medicare charges from 2009!

DocSite PQRI makes it simple – click here to learn more.

-- PATIENTS,please remember email may not be entirely secure and that Email is part of the medical record and is placed into the chart ( be careful what you say!)Email is best used for appointment making and brief questionsEmail replies can be expected within 24 hours-Please CALL if the matter is more urgent . MD ph fax impcenter.org

Hotmail: Trusted email with Microsoft’s powerful SPAM protection. Sign up now.

-- PATIENTS,please remember email may not be entirely secure and that Email is part of the medical record and is placed into the chart ( be careful what you say!)Email is best used for appointment making and brief questionsEmail replies can be expected within 24 hours-Please CALL if the matter is more urgent . MD ph fax impcenter.org

Hotmail: Free, trusted and rich email service. Get it now.

January 14, 2010

OK, ear candle -- are you trying to tell a person to melt the wax in their ear with a candle?

Please tell me this is NOT something you ACTUALLY RECOMMEND to a pt??????????????????????

Re: [Practiceimprovemen t1] Re: PQRI

thanks I am working my way up to this . I remember Gordon tried to introduce the first IMPs to doc Site. Does doc site provide Valium? Will you need extra visits with RAmona when I complain? AH this could be good for Ramona if I do PQRI!Jean

On Tue, Jan 12, 2010 at 8:50 AM, Haughton MD, MS <jhaughtondocsite (DOT) com> wrote:

is right – it appears that PQRI (and its ability to report structured clinical data – either directly or as numerator / denominator info is a key part of health reform / payment reform – paying based on quality, cost [ risk adjusted expected vs observed gainsharing on top of fee for service? ] and patient satisfaction – which should put the IMP practices in good stead (vs current system of paying fully for volume of service). Regarding my offer for PQRI @ $250 a user and trust and is it worth it:1) Ramona Seidel is my physician2) I’ve been working with Gordon and others for about a dozen years, trying to make scalable quality healthcare a reality3) Some IMPs have used docSite’s old system – its registry (which is a core, core part of our current and ongoing offering that can augment an EMR/ EHR or act as an EMR/EHR for meaningful use payments) Regarding is PQRI worth it – If you don’t have about $50,000 of medicare billing, it really may not be worth the hassle. BUT, whether through AAFP (for Diabetes) or DocSite (for prevention or diabetes or other) or another program (there are about 70 options out there this year) --- it should take about 2 or 3 hours to accomplish the activities associated with collecting, and submitting data on 30 consecutive patients. In 2008, we had many primary care physicians who received as much as a few thousand $. Many received $800-$1500. Some surgeons received as much as $15K or $20K. In short if you are doing Diabetes – use the AAFP site. If you are doing prevention and want to use a system run by a physician who cares about quality, feel free to use the discount code I put in the last e-mail ThankYou08 to make the cost $250 instead of $350. Thanks – Haughton MD, MSChair / CMOoffice: mobile: fax: Raleigh | poliswww.docsite. com Don’t miss the opportunity to earn a bonus payment of up to 2% of your total allowed Medicare charges from 2009! DocSite PQRI makes it simple – click here to learn more. -- PATIENTS,please remember email may not be entirely secure and that Email is part of the medical record and is placed into the chart ( be careful what you say!)Email is best used for appointment making and brief questionsEmail replies can be expected within 24 hours-Please CALL if the matter is more urgent . MD ph fax impcenter.org

Hotmail: Trusted email with Microsoft’s powerful SPAM protection. Sign up now.

-- PATIENTS,please remember email may not be entirely secure and that Email is part of the medical record and is placed into the chart ( be careful what you say!)Email is best used for appointment making and brief questionsEmail replies can be expected within 24 hours-Please CALL if the matter is more urgent . MD ph fax impcenter.org

Hotmail: Free, trusted and rich email service. Get it now.

January 14, 2010

Matt, You haven’t heard of candling. Done widely.

However, I found this in AFP:

Home cerumen treatments

are not unusual, and many of the treatments mentioned above are available over

the counter alone or in earwax removal kits. Cotton ear buds are not

definitively associated with cerumen impaction, but they have been implicated

in impaction and otitis externa and should be avoided.26–28

Ear candling also should

be avoided. Ear candling is a practice in which a hollow candle is inserted

into the external auditory canal and lit, with the patient lying on the

opposite ear. In theory, the combination of heat and suction is supposed to

remove earwax. However, in one trial, ear candles neither created suction nor

removed wax and actually led to occlusion with candle wax in persons who

previously had clean ear canals. Primary care physicians may see complications

from ear candling including candle wax occlusion, local burns, and tympanic

membrane perforation.8,29

I have read other reports that the candles don’t really

create negative pressure, and when they have analyzed the “debris”

in the candle it wasn’t ear wax at all. I wouldn’t recommend it at

all.

Kathy Saradarian, MD

Branchville, NJ

www.qualityfamilypractice.com

Solo 4/03, Practicing since 9/90

Practice Partner 5/03

Low staffing

From:

[mailto: ] On Behalf Of Dr Levin

Sent: Wednesday, January 13, 2010 9:54 PM

To:

Subject: Re: cerumen removal

OK,

ear candle -- are you trying to tell a person to melt the wax in their ear with

a candle?

Please

tell me this is NOT something you ACTUALLY RECOMMEND to a pt??????????????????????

-----

Original Message -----

From: Helen Yang

To: practiceimprovement1

Sent: Wednesday, January 13,

2010 8:52 PM

Subject: RE:

cerumen removal

BCBS here pays about $50 for cerumen removal.

Wholefoods sells ear candles that would work well for most people, though may

be hard for the elderly to manage this DIY .

Helen

To:

From: dr_levin@...

Date: Wed, 13 Jan 2010 18:49:00 -0500

Subject: Re: , please help to check the

billing/coding rules

Bill

as ear pain, don't bill removal earwax at all -- E & M pays better

-----

Original Message -----

From: Jean

Antonucci

To:

Sent: Wednesday, January

13, 2010 8:30 AM

Subject: Re:

, please help to check the billing/coding rules

Helen just watch out for

cerumen removal

Cerumen removal coding is extra points on t he billing trivia exam

IF THEY HAVE MEDICARE it is a no n ono to do cerumen removal and anythign

else at the same time( and b epaid) Heaven knows who invented that one

It is after all MUCH better for elderly frail folks with

hearing aids and accumulated wax to call their daughteranother time and come

out again and buy more gas and the daughter h as to take more time off

work or gather up her babies and fire up the stroller and

diaper bag and crackers and other take the baby out parapharnalia and

find parking etc etc to bring mom in agian becasue when mom came in last

week for her physical which of course medicare does not allow but

mom wants and or anything else, one can look but not touch

the cerumen

Got tha?t Cerumen and medicare--separete visits NO modifiers

allowed

Cerumen and nonmedicare- sure -25.

Now please compare and contrast par , non par, and opted out. YOu have 3

lines and 15minutes(No cheating off MEgan)

SIgh

jean

Dear ,

Thank you for your strong support to help to get my IMP off the groud. I am

getting ready to submit claims.

Could you please confirm that the following is correct:

1. when bill EM office visit with a physical, use -25 with 99214, not with the

physical code for the age of pt

2. when bill 99354 (prolonged visit) in addition to 99214, no modifier is

needed

3. in house labs strep, UA, glucose, EKG done during OV don't need

modifier (one other biller told em taht I do need -25 for glucose finger

stick check, which one is correct?).

4. These done during OV need -25 : anoscopic exam, cerumen removal, trigger

point injection, peak flow, skin lesion removal procedures

5. These done during ov don't need -25: vaccine 9Which box on the form

1500 do I put in vaccine code and where to put in the administration of vac

code?

6 B12 shot- no modifier when done without OV, yes to use -125 if done with OV.

7. When and how to use -59?

8. How to client bill the labs with and without OV?

Thank you very much in deed for your kind help.

Helen

To:

From: karen.oaktree@...

Date: Tue, 12 Jan 2010 16:56:10 -0800

Subject: RE: Re: PQRI

Here is what we code (Internal

Medicine office), for anyone who’s interested:

e-RX: (2% bonus from CMS this year and

next, 1% penalty starting in 2011)

G8443 – rx electronically submitted (note that this means that you sent

the rx electronically, not just generated from your EMR)

G8445 – no rx’s generated

G8446 – rx prescribed, but not electronically submitted

EMR: (this is what will eventually partially

qualify you for being eligible for stimulus package money)

G8447 – Encounter done on CCHIT Certified HER

G8448 – Encounter done on non-CCHIT Certified EHR

For PQRI, Steve is reporting on LDL,

BP, and A1C’s for diabetics, antiplatelet therapy for CAD and the measure

for osteoporosis. For all measures, if the patient is “not

eligible” (I’m not sure what that exactly means – it’s

his note to himself), then you use a modifier 8P. There are many other

options, you need to review them on the CMS website and decide for yourself

which ones are the easiest for you to submit. The codes are:

DM – reported once per year per

patient:

3044F

– A1C <7

3045F

– A1C 7-9

3046F

– A1C >9

DM – reported once per year per

patient:

3048F

– LDL <100

3049F

– LDL 100-129

3049F

– LDL 130+

DM – BP (reported every time)

3074F

– sbp <130

3075F

– sbp 130-139

3076F

– sbp 140+

3078F

– dbp <80

3079F

– dbp 80-89

3080F

– dbp 90+

2000F-8P

– BP not done

CAD (aspirin, Plavix, or

depyridamole) – Note that other providers might freak out when they see

4011F-1P because it may print out on the note as “oral antiplatelet

prescribed”, when the modifier -1P is stating that it wasn’t

prescribed

4011F –

oral antiplatelet prescribed

Mod -1P –

Not done for medical reason

Mod -2P

– Not done for patient reason

Mod -3P

– not done for system reason

Pratt

Office Manager

Oak Tree Internal Medicine P.C

www.prattmd.info

From:

[mailto: ]

On Behalf Of Pratt

Sent: Tuesday, January 12, 2010 4:43 PM

To:

Subject: RE: Re: PQRI

Let me find it….I posted it

to the list earlier (or maybe I just sent it to someone).

Pratt

Office Manager

Oak Tree Internal Medicine P.C

www.prattmd.info

From:

[mailto: ]

On Behalf Of Myria

Sent: Tuesday, January 12, 2010 4:22 PM

To:

Subject: Re: Re: PQRI

Can I get copy of the cheat

sheet?

To:

Sent: Tue, January 12, 2010 2:01:29 PM

Subject: RE: Re: PQRI

I would recommend claims-based

reporting for 2010, since we’re at the beginning of the year. It

takes very little time to add the codes to your outbound claims and is

FREE. Steve has a cheat sheet on his desk with about 20 or 30 codes on

it; he simply adds the code at the end of the visit and it goes out on the

claim for that visit. I’d estimate it takes him less than 30

seconds per patient to do this. That’s a maximum amount of time

spent of 15 minutes per 30 patients.

Pratt

Office Manager

Oak Tree Internal Medicine P.C

www.prattmd.

info

From: Practiceimprovement 1yahoogroups (DOT) com

[mailto: Practiceimprovement 1yahoogroups (DOT) com ] On Behalf Of Will

Conner

Sent: Tuesday, January 12, 2010 6:56 AM

To: Practiceimprovement 1yahoogroups (DOT) com

Subject: RE: [Practiceimprovemen t1] Re: PQRI

Can we do this without paying a

fee when we use the AAFP or AFM web-site?

J. Conner,

M.D.

211 West

s St

s,

N.C. 28105

Note: Privileged/confiden tial information may be

contained in this message and may be subject to legal privilege. Access to this

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From: Practiceimprovement 1yahoogroups (DOT) com

[mailto: Practiceimp rovement1@ yahoogroups. com ] On Behalf Of Jean

Antonucci

Sent: Tuesday, January 12, 2010 8:55 AM

To: Practiceimprovement 1yahoogroups (DOT) com

Subject: Re: [Practiceimprovemen t1] Re: PQRI

thanks I am working my

way up to this . I remember Gordon tried to introduce the first IMPs to doc

Site. Does doc site provide Valium? Will you need extra visits with

RAmona when I complain? AH this could be good for Ramona if I

do PQRI!

Jean

On Tue, Jan 12, 2010 at 8:50 AM,

Haughton MD, MS <jhaughtondocsite (DOT)

com> wrote:

is right – it appears

that PQRI (and its ability to report structured clinical data – either

directly or as numerator / denominator info is a key part of health reform /

payment reform – paying based on quality, cost [ risk adjusted expected

vs observed gainsharing on top of fee for service? ] and patient

satisfaction – which should put the IMP practices in good stead (vs

current system of paying fully for volume of service).

Regarding my offer for PQRI @ $250 a user and trust and is it worth it:

1) Ramona

Seidel is my physician

2) I’ve

been working with Gordon and others for about a dozen years, trying to

make scalable quality healthcare a reality

3) Some IMPs

have used docSite’s old system – its registry (which is a core,

core part of our current and ongoing offering that can augment an EMR/ EHR or

act as an EMR/EHR for meaningful use payments)

Regarding is PQRI worth it – If you don’t have about $50,000 of

medicare billing, it really may not be worth the hassle. BUT, whether

through AAFP (for Diabetes) or DocSite (for prevention or diabetes or other) or

another program (there are about 70 options out there this year) --- it should

take about 2 or 3 hours to accomplish the activities associated with

collecting, and submitting data on 30 consecutive patients. In

2008, we had many primary care physicians who received as much as a few

thousand $. Many received $800-$1500. Some surgeons received

as much as $15K or $20K.

In short if you are doing Diabetes – use the AAFP site. If you are

doing prevention and want to use a system run by a physician who cares about

quality, feel free to use the discount code I put in the last e-mail

ThankYou08 to make the cost $250 instead of $350.

Thanks –

Haughton MD, MS

Chair / CMO

office:

mobile:

fax:

Raleigh | polis

www.docsite.

com

Don’t miss the opportunity

to earn a bonus payment of up to 2% of your total allowed Medicare charges from

2009!

DocSite PQRI makes it simple

– click here to learn more.

--

PATIENTS,please remember email may not be entirely secure and that Email is

part of the medical record and is placed into the chart ( be careful what

you say!)

Email is best used for appointment making and brief questions

Email replies can be expected within 24 hours-Please CALL if the

matter is more urgent .

MD

ph fax

impcenter.org

Hotmail: Trusted email with

Microsoft’s powerful SPAM protection. Sign up now.

--

PATIENTS,please remember email may not be entirely secure and that Email is

part of the medical record and is placed into the chart ( be careful what

you say!)

Email is best used for appointment making and brief questions

Email replies can be expected within 24 hours-Please CALL if the

matter is more urgent .

MD

ph fax

impcenter.org

Hotmail: Free, trusted and rich email service. Get it

now.

January 14, 2010

Yep, and those side effects are the reason NOT to do it.......................

Re: [Practiceimprovemen t1] Re: PQRI

thanks I am working my way up to this . I remember Gordon tried to introduce the first IMPs to doc Site. Does doc site provide Valium? Will you need extra visits with RAmona when I complain? AH this could be good for Ramona if I do PQRI!Jean

On Tue, Jan 12, 2010 at 8:50 AM, Haughton MD, MS <jhaughtondocsite (DOT) com> wrote:

is right – it appears that PQRI (and its ability to report structured clinical data – either directly or as numerator / denominator info is a key part of health reform / payment reform – paying based on quality, cost [ risk adjusted expected vs observed gainsharing on top of fee for service? ] and patient satisfaction – which should put the IMP practices in good stead (vs current system of paying fully for volume of service). Regarding my offer for PQRI @ $250 a user and trust and is it worth it:1) Ramona Seidel is my physician2) I’ve been working with Gordon and others for about a dozen years, trying to make scalable quality healthcare a reality3) Some IMPs have used docSite’s old system – its registry (which is a core, core part of our current and ongoing offering that can augment an EMR/ EHR or act as an EMR/EHR for meaningful use payments) Regarding is PQRI worth it – If you don’t have about $50,000 of medicare billing, it really may not be worth the hassle. BUT, whether through AAFP (for Diabetes) or DocSite (for prevention or diabetes or other) or another program (there are about 70 options out there this year) --- it should take about 2 or 3 hours to accomplish the activities associated with collecting, and submitting data on 30 consecutive patients. In 2008, we had many primary care physicians who received as much as a few thousand $. Many received $800-$1500. Some surgeons received as much as $15K or $20K. In short if you are doing Diabetes – use the AAFP site. If you are doing prevention and want to use a system run by a physician who cares about quality, feel free to use the discount code I put in the last e-mail ThankYou08 to make the cost $250 instead of $350. Thanks – Haughton MD, MSChair / CMOoffice: mobile: fax: Raleigh | poliswww.docsite. com Don’t miss the opportunity to earn a bonus payment of up to 2% of your total allowed Medicare charges from 2009! DocSite PQRI makes it simple – click here to learn more.

-- PATIENTS,please remember email may not be entirely secure and that Email is part of the medical record and is placed into the chart ( be careful what you say!)Email is best used for appointment making and brief questionsEmail replies can be expected within 24 hours-Please CALL if the matter is more urgent . MD ph fax impcenter.org

Hotmail: Trusted email with Microsoft’s powerful SPAM protection. Sign up now.

-- PATIENTS,please remember email may not be entirely secure and that Email is part of the medical record and is placed into the chart ( be careful what you say!)Email is best used for appointment making and brief questionsEmail replies can be expected within 24 hours-Please CALL if the matter is more urgent . MD ph fax impcenter.org

Hotmail: Free, trusted and rich email service. Get it now.

January 14, 2010

Ear

candling is not unusual here in the mountains. Some salons even offer it as a

service. I don’t recommend it, but I had an elderly lady whose EACs

were chock full of cerumen. She came back a week later for follow up of another

issue, and her ears were perfectly clear. I asked what she did to get the wax

out, and she said she used ear candles. I can’t explain it, but I was

surprised and impressed. However, I’ve seen other pts who have also

candled, and their EACs were still occluded. They tell me the wax they used

was white, and it came out of their ear with some brown (presumed cerumen) mixed

in it. I am skeptical, and a perforated TM is scary…

Eads, MD

Pinnacle

Family Medicine

Colorado

Springs, Colorado

www.PinnacleFamilyMedicine.com

From:

[mailto: ] On Behalf Of Kathy

Saradarian

Sent: Wednesday, January 13, 2010 8:16 PM

To:

Subject: RE: cerumen removal

Matt, You haven’t heard of

candling. Done widely. However, I found this in AFP:

Home cerumen treatments

are not unusual, and many of the treatments mentioned above are available over

the counter alone or in earwax removal kits. Cotton ear buds are not definitively

associated with cerumen impaction, but they have been implicated in impaction

and otitis externa and should be avoided.26–28

Ear candling also should

be avoided. Ear candling is a practice in which a hollow candle is inserted

into the external auditory canal and lit, with the patient lying on the

opposite ear. In theory, the combination of heat and suction is supposed to

remove earwax. However, in one trial, ear candles neither created suction nor

removed wax and actually led to occlusion with candle wax in persons who

previously had clean ear canals. Primary care physicians may see complications

from ear candling including candle wax occlusion, local burns, and tympanic

membrane perforation.8,29

I have read other reports that the

candles don’t really create negative pressure, and when they have

analyzed the “debris” in the candle it wasn’t ear wax at

all. I wouldn’t recommend it at all.

Kathy

Saradarian, MD

Branchville,

NJ

www.qualityfamilypractice.com

Solo 4/03,

Practicing since 9/90

Practice

Partner 5/03

Low staffing

From:

[mailto: ]

On Behalf Of Dr Levin

Sent: Wednesday, January 13, 2010 9:54 PM

To:

Subject: Re: cerumen removal

OK, ear candle -- are you trying to tell a person to

melt the wax in their ear with a candle?

Please tell me this is NOT something you ACTUALLY

RECOMMEND to a pt??????????????????????

Re: [Practiceimprovemen t1] Re: PQRI

thanks I am working my way up to this . I remember

Gordon tried to introduce the first IMPs to doc Site. Does doc site

provide Valium? Will you need extra visits with RAmona when I

complain? AH this could be good for Ramona if I do PQRI!

Jean

On Tue, Jan 12, 2010 at 8:50 AM, Haughton MD, MS <jhaughtondocsite (DOT) com> wrote:

is right – it appears that PQRI (and its ability

to report structured clinical data – either directly or as numerator /

denominator info is a key part of health reform / payment reform – paying

based on quality, cost [ risk adjusted expected vs observed gainsharing on top

of fee for service? ] and patient satisfaction – which should put

the IMP practices in good stead (vs current system of paying fully for volume

of service).