Re: INR in Office - options for machine

October 31, 2008

Hi ,

We just started our “ATC”

(Anti-coagulation Therapy Clinic) last week. We are doing it Tuesdays and

Fridays for an hour each day, for a grand total of 8 patients/week.

We have about 15 patients currently on warfarin.

So far, the patients love it. They

like that it is only a finger stick and they like that they are told right here

what their dose will be and we schedule them for followup, based on the

protocol.

Since we just started last week, we’ll

see how it comes back in the billing. Next week, the schedule is

full. If the schedule continues to stay full, we will add another day for

1 hour, and continue in that format until we have 5-1hour days. We are

giving this 2 months to get the kinks worked out and then we’re going to

market it to other solo docs in the area. The only local Coumadin clinic

is in a neighboring town’s hospital and you have to be on staff there to

send patients there.

We got our machine through our

Medical Rep. We purchased 5 boxes of strips, and got the machine, 1 box

of wipes (to clean the machine with), and a box of lancets for about what the

machine would have cost.

Good luck,

Pratt

Office Manager

Oak Tree Internal Medicine P.C.

From: [mailto: ] On Behalf Of Locke

Sent: Thursday, October 30, 2008

1:22 PM

Subject:

INR in Office - options for machine

Does anyone know if there are INR machine companies that basically give

you the machine if you buy the strips, etc, from them?

A couple primary care docs in our office are considering doing a

coumadin clinic and wondered about our options.

I know some of you are doing INR clinics with the patient having a

nurse visit and giving the results and changes at the time of service.

How is that going for you?

We've already got the Clia waiver, so should be good to go -- just need

the machine.

Locke, MD

October 31, 2008

,

I got a couple of INRatio machines for free when I started

my practice as part of a deal that involved buying a year’s worth of

Cholestech supplies for lipid testing. I sold one of the machines for a

very low price to someone on this list.

The supplies for the machine cost about what the Medicare

payment for the test is, and if you figure you will occasionally need to repeat

a test, it turns out that there is no real profit from doing this, unless you

can charge a visit charge. Unfortunately, if you charge a visit

charge, the patient has to pay a co-pay, which they would not have to pay if

they got the test at the lab. I imagine that in some locales, this would

be fine, but we have lots of places where they can go locally for the test at

no charge, so most of my patients prefer to go to the local lab or to one of

the hospital-sponsored coagulation clinics.

So, most of the time when I do an INR, I do it as part of a

scheduled visit for something else. In that case, I can usually charge

for a higher level visit because of the extra time and complexity of the

visit. For those patients who choose to go to the lab to get the

INR, I review the results and address the dosing issues without any charge, but

I do insist that they come and see me for some kind of a visit every few months.

For insurances like United Health Care, which only pay 2/3 of the actual cost

of the test strips, I draw the blood and send it to the lab, which at least

pays me $3.00 for the blood draw, rather than costing me a couple of dollars

beyond what I can get paid for doing it in the office.

So, if you can get the machine for free or for a very low cost, the

convenience of being able to get a quick result and of dealing with the

results while the patient is there makes in-office testing a break-even deal,

at best. If you are in a location where the patients would be

willing to pay a co-pay for the convenience of doing it at your office, then

you could actually make money on the testing, especially if you have staff who

have the time to do the visit, follow your protocol, and document things

appropriately.

dts

From:

[mailto: ] On Behalf Of Locke

Sent: Thursday, October 30, 2008 1:22 PM

Subject: INR in Office - options for machine

Does anyone know if there are INR machine companies that

basically give you the machine if you buy the strips, etc, from them?

A couple primary care docs in our office are considering

doing a coumadin clinic and wondered about our options.

I know some of you are doing INR clinics with the patient

having a nurse visit and giving the results and changes at the time of service.

How is that going for you?

We've already got the Clia waiver, so should be good to go

-- just need the machine.

Locke, MD

October 31, 2008

Our experience for the past 5 years or so is the same as 's.

90 % of patients are happy to do test in our office. The 99211 plus fingerstick are "profit".

The strips - ie actual test are a breakeven. But that is 90% less free work and phone calls you would be doing anyway.

Copay for medicare on 99211 is about $4 so it is not a limiting factor for patients, not to mention that the majority have a secondary insurance anyway. Our biggest HMO does not charge a copay for a 99211.

Most office supply companies will offer a "deal" like describes. We purchased ours thru PSS.

BTW - we dont have a "coumadin clinic time". We just schedule nurse visits during the day while a doctor is there. If MD needs to adjust coumadin, we usually up the charge to a 99212.

Mike S.

McCain or Obama? Stay up to date on the latest from the campaign trail with

AOL News.

November 1, 2008

Hi, ,

Thank you for the information. I currently send my patients to the hospital coumadin clinic which is a big nuisance for them secondary to traffic jams and parking fees.

What are you charging your patients for the care? Do they pay co-pays if you charge level 1?

Alla Kirsch, M.D.

Solo family practitioner in Cleveland

Subject: RE: INR in Office - options for machineTo: Date: Thursday, October 30, 2008, 7:07 PM

Hi ,

We just started our “ATC” (Anti-coagulation Therapy Clinic) last week. We are doing it Tuesdays and Fridays for an hour each day, for a grand total of 8 patients/week. We have about 15 patients currently on warfarin.

So far, the patients love it. They like that it is only a finger stick and they like that they are told right here what their dose will be and we schedule them for followup, based on the protocol.

Since we just started last week, we’ll see how it comes back in the billing. Next week, the schedule is full. If the schedule continues to stay full, we will add another day for 1 hour, and continue in that format until we have 5-1hour days. We are giving this 2 months to get the kinks worked out and then we’re going to market it to other solo docs in the area. The only local Coumadin clinic is in a neighboring town’s hospital and you have to be on staff there to send patients there

November 1, 2008

Hi, ,

Thank you for the information. I currently send my patients to the hospital coumadin clinic which is a big nuisance for them secondary to traffic jams and parking fees.

What are you charging your patients for the care? Do they pay co-pays if you charge level 1?

Alla Kirsch, M.D.

Solo family practitioner in Cleveland

Subject: RE: INR in Office - options for machineTo: Date: Thursday, October 30, 2008, 7:07 PM

Hi ,

We just started our “ATC” (Anti-coagulation Therapy Clinic) last week. We are doing it Tuesdays and Fridays for an hour each day, for a grand total of 8 patients/week. We have about 15 patients currently on warfarin.

So far, the patients love it. They like that it is only a finger stick and they like that they are told right here what their dose will be and we schedule them for followup, based on the protocol.

Since we just started last week, we’ll see how it comes back in the billing. Next week, the schedule is full. If the schedule continues to stay full, we will add another day for 1 hour, and continue in that format until we have 5-1hour days. We are giving this 2 months to get the kinks worked out and then we’re going to market it to other solo docs in the area. The only local Coumadin clinic is in a neighboring town’s hospital and you have to be on staff there to send patients there

November 3, 2008

Hi Alla,

We charge as follows:

99211 – office visit (copay applies)

36416 – finger stick

85610-QW – INR testing

I don’t know off the top of my head what

the actual charges are – somewhere around $50. We don’t see any cash pay

patients for that.

Pratt

Office Manager

Oak Tree Internal Medicine P.C.

From: [mailto: ] On Behalf Of Alla Kirsch

Sent: Saturday, November 01, 2008

11:18 AM

To:

Subject: RE:

INR in Office - options for machine

Hi, ,

Thank you for the information. I currently

send my patients to the hospital coumadin clinic which is a big nuisance for

them secondary to traffic jams and parking fees.

What are you charging your patients for the care? Do

they pay co-pays if you charge level 1?

Alla Kirsch, M.D.

Solo family practitioner in Cleveland

From: Pratt

<karen.oaktreecomcast (DOT) net>

Subject: RE: INR in Office - options for machine

To:

Date: Thursday, October 30, 2008, 7:07 PM

Hi ,

We just started our “ATC” (Anti-coagulation Therapy Clinic) last

week. We are doing it Tuesdays and Fridays for an hour each day, for a

grand total of 8 patients/week. We have about 15 patients

currently on warfarin.

So far, the patients love it. They like that it is only a

finger stick and they like that they are told right here what their dose will

be and we schedule them for followup, based on the protocol.

Since we just started last week, we’ll see how it comes back in

the billing. Next week, the schedule is full. If the schedule

continues to stay full, we will add another day for 1 hour, and continue in

that format until we have 5-1hour days. We are giving this 2 months to

get the kinks worked out and then we’re going to market it to other solo docs

in the area. The only local Coumadin clinic is in a neighboring town’s

hospital and you have to be on staff there to send patients there.

We got our machine through our Medical Rep. We

purchased 5 boxes of strips, and got the machine, 1 box of wipes (to clean

the machine with), and a box of lancets for about what the machine would have

cost.

Good luck,

Pratt

Office Manager

Oak Tree Internal Medicine P.C.

From: Practiceimprovement

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

Sent: Thursday, October 30, 2008

1:22 PM

Subject: [Practiceimprovemen t1]

INR in Office - options for machine

Does anyone know

if there are INR machine companies that basically give you the machine if you

buy the strips, etc, from them?

A couple primary

care docs in our office are considering doing a coumadin clinic and wondered

about our options.

I know some of

you are doing INR clinics with the patient having a nurse visit and giving

the results and changes at the time of service.

How is that

going for you?

We've already

got the Clia waiver, so should be good to go -- just need the machine.

Locke, MD

November 9, 2008

Thanks .

INR's are irritating.

They are not low risk labs and so require input from the doctor in a timely matter.

Yes, patients balk at copays to do a nurse visit, but on the other hand, the second I screw up and the patient strokes, I'm on the hook.

Good points on reimbursement -- and how they suck -- unless you do an actual visit.

I'll keep that in mind.

Locke, MD

From: [mailto: ] On Behalf Of T. , MDSent: Thursday, October 30, 2008 11:52 PMTo: Subject: RE: INR in Office - options for machine

,

I got a couple of INRatio machines for free when I started my practice as part of a deal that involved buying a year’s worth of Cholestech supplies for lipid testing. I sold one of the machines for a very low price to someone on this list.

The supplies for the machine cost about what the Medicare payment for the test is, and if you figure you will occasionally need to repeat a test, it turns out that there is no real profit from doing this, unless you can charge a visit charge. Unfortunately, if you charge a visit charge, the patient has to pay a co-pay, which they would not have to pay if they got the test at the lab. I imagine that in some locales, this would be fine, but we have lots of places where they can go locally for the test at no charge, so most of my patients prefer to go to the local lab or to one of the hospital-sponsored coagulation clinics.

So, most of the time when I do an INR, I do it as part of a scheduled visit for something else. In that case, I can usually charge for a higher level visit because of the extra time and complexity of the visit. For those patients who choose to go to the lab to get the INR, I review the results and address the dosing issues without any charge, but I do insist that they come and see me for some kind of a visit every few months. For insurances like United Health Care, which only pay 2/3 of the actual cost of the test strips, I draw the blood and send it to the lab, which at least pays me $3.00 for the blood draw, rather than costing me a couple of dollars beyond what I can get paid for doing it in the office.

So, if you can get the machine for free or for a very low cost, the convenience of being able to get a quick result and of dealing with the results while the patient is there makes in-office testing a break-even deal, at best. If you are in a location where the patients would be willing to pay a co-pay for the convenience of doing it at your office, then you could actually make money on the testing, especially if you have staff who have the time to do the visit, follow your protocol, and document things appropriately.

dts

From: [mailto: ] On Behalf Of LockeSent: Thursday, October 30, 2008 1:22 PMSubject: INR in Office - options for machine

Does anyone know if there are INR machine companies that basically give you the machine if you buy the strips, etc, from them?

A couple primary care docs in our office are considering doing a coumadin clinic and wondered about our options.

I know some of you are doing INR clinics with the patient having a nurse visit and giving the results and changes at the time of service.

How is that going for you?

We've already got the Clia waiver, so should be good to go -- just need the machine.

Locke, MD

November 10, 2008

We do both. Nurse or MD visit - usually 99211, 12, or 13 - for each INR in office.

We also see pt. for regular visits every 3 to 6 months like all who have chronic medical problems. Would typically bill a 99214 or 99215 depending on complexity and time. Of course, if they are due for or situation calls for INR during their follow up or acute visit, we will do it at that time.Most importantly, we are charging $60 q 3 months for coumadin management via telephone (there is a code) for those patients who prefer to have INR drawn at lab. Our largest HMO reimburses about $45. Or $20 if it is an occasional lab draw (like when patient is out of area on vacation.) We would usually bill this as a brief telephone visit. Why spend all that time and incur liability doing it for free?

After an explanation of reason, we have had only one patient put up much of a complaint. She is an artist and travels alot and wrote that we were trying to curtail her independence in her waning years by forcing her to come to our office regularly!! Of course her INR was all over the place and we would spend days trying to track her down to make adjustments. We are happy to let the cardiologist's office handle her via their "coumadin clinic".

Mike S.

10a.

Re: INR in Office - options for machine

Posted by: " Locke"

lockecolorado@...

familylocke

Sun Nov 9, 2008 2:49 pm (PST)

Thanks .

INR's are irritating.

They are not low risk labs and so require input from the doctor in a timely

matter.

Yes, patients balk at copays to do a nurse visit, but on the other hand, the

second I screw up and the patient strokes, I'm on the hook.

Good points on reimbursement -- and how they suck -- unless you do an actual

visit.

I'll keep that in mind.

Locke, MD

_____

From:

[mailto: ] On Behalf Of T.

, MD

Sent: Thursday, October 30, 2008 11:52 PM

To:

Subject: RE: INR in Office - options for machine

,

I got a couple of INRatio machines for free when I started my practice as

part of a deal that involved buying a year's worth of Cholestech supplies

for lipid testing. I sold one of the machines for a very low price to

someone on this list.

The supplies for the machine cost about what the Medicare payment for the

test is, and if you figure you will occasionally need to repeat a test, it

turns out that there is no real profit from doing this, unless you can

charge a visit charge. Unfortunately, if you charge a visit charge, the

patient has to pay a co-pay, which they would not have to pay if they got

the test at the lab. I imagine that in some locales, this would be fine,

but we have lots of places where they can go locally for the test at no

charge, so most of my patients prefer to go to the local lab or to one of

the hospital-sponsored coagulation clinics.

So, most of the time when I do an INR, I do it as part of a scheduled visit

for something else. In that case, I can usually charge for a higher level

visit because of the extra time and complexity of the visit. For those

patients who choose to go to the lab to get the INR, I review the results

and address the dosing issues without any charge, but I do insist that they

come and see me for some kind of a visit every few months. For insurances

like United Health Care, which only pay 2/3 of the actual cost of the test

strips, I draw the blood and send it to the lab, which at least pays me

$3.00 for the blood draw, rather than costing me a couple of dollars beyond

what I can get paid for doing it in the office.

So, if you can get the machine for free or for a very low cost, the

convenience of being able to get a quick result and of dealing with the

results while the patient is there makes in-office testing a break-even

deal, at best. If you are in a location where the patients would be

willing to pay a co-pay for the convenience of doing it at your office, then

you could actually make money on the testing, especially if you have staff

who have the time to do the visit, follow your protocol, and document things

appropriately.

dts

From:

[mailto: ] On Behalf Of Locke

Sent: Thursday, October 30, 2008 1:22 PM

Subject: INR in Office - options for machine

Does anyone know if there are INR machine companies that basically give you

the machine if you buy the strips, etc, from them?

A couple primary care docs in our office are considering doing a coumadin

clinic and wondered about our options.

I know some of you are doing INR clinics with the patient having a nurse

visit and giving the results and changes at the time of service.

How is that going for you?

We've already got the Clia waiver, so should be good to go -- just need the

machine.

Locke, MD

Instant access to the latest most popular FREE games while you browse with the Games Toolbar - Download Now!

November 10, 2008

Thanks for sharing. Do you bill it during the office visit or separtely? What is the actural code? What determines 45 vs 20? If monthly the HMO will pay 20 and if more than that when adjusting the 45? I was thinking I was just going to have to swallow the lost money on these patients.

Subject: Re: INR in Office - options for machineTo: Date: Monday, November 10, 2008, 7:46 AM

We do both. Nurse or MD visit - usually 99211, 12, or 13 - for each INR in office.

We also see pt. for regular visits every 3 to 6 months like all who have chronic medical problems. Would typically bill a 99214 or 99215 depending on complexity and time. Of course, if they are due for or situation calls for INR during their follow up or acute visit, we will do it at that time.Most importantly, we are charging $60 q 3 months for coumadin management via telephone (there is a code) for those patients who prefer to have INR drawn at lab. Our largest HMO reimburses about $45. Or $20 if it is an occasional lab draw (like when patient is out of area on vacation.) We would usually bill this as a brief telephone visit. Why spend all that time and incur liability doing it for free? After an explanation

of reason, we have had only one patient put up much of a complaint. She is an artist and travels alot and wrote that we were trying to curtail her independence in her waning years by forcing her to come to our office regularly!! Of course her INR was all over the place and we would spend days trying to track her down to make adjustments. We are happy to let the cardiologist' s office handle her via their "coumadin clinic". Mike S.

10a.

Re: INR in Office - options for machine

Posted by: " Locke" lockecolorado@ gmail.com familylocke

Sun Nov 9, 2008 2:49 pm (PST)

Thanks . INR's are irritating.They are not low risk labs and so require input from the doctor in a timelymatter. Yes, patients balk at copays to do a nurse visit, but on the other hand, thesecond I screw up and the patient strokes, I'm on the hook.Good points on reimbursement -- and how they suck -- unless you do an actualvisit.I'll keep that in mind. Locke, MD_____ From: Practiceimprovement 1yahoogroups (DOT) com[mailto:Practiceimprovement 1yahoogroups (DOT) com] On Behalf Of T., MDSent: Thursday, October 30, 2008 11:52 PMTo: Practiceimprovement 1yahoogroups (DOT)

comSubject: RE: [Practiceimprovemen t1] INR in Office - options for machine,I got a couple of INRatio machines for free when I started my practice aspart of a deal that involved buying a year's worth of Cholestech suppliesfor lipid testing. I sold one of the machines for a very low price tosomeone on this list. The supplies for the machine cost about what the Medicare payment for thetest is, and if you figure you will occasionally need to repeat a test, itturns out that there is no real profit from doing this, unless you cancharge a visit charge. Unfortunately, if you charge a visit charge, thepatient has to pay a co-pay, which they would not have to pay if they gotthe test at the lab. I imagine that in some locales, this would be fine,but we have lots of places where they can go locally for the test at nocharge, so most of my patients prefer to go to the local lab or to one

ofthe hospital-sponsored coagulation clinics. So, most of the time when I do an INR, I do it as part of a scheduled visitfor something else. In that case, I can usually charge for a higher levelvisit because of the extra time and complexity of the visit. For thosepatients who choose to go to the lab to get the INR, I review the resultsand address the dosing issues without any charge, but I do insist that theycome and see me for some kind of a visit every few months. For insuranceslike United Health Care, which only pay 2/3 of the actual cost of the teststrips, I draw the blood and send it to the lab, which at least pays me$3.00 for the blood draw, rather than costing me a couple of dollars beyondwhat I can get paid for doing it in the office. So, if you can get the machine for free or for a very low cost, theconvenience of being able to get a quick result and of dealing with theresults

while the patient is there makes in-office testing a break-evendeal, at best. If you are in a location where the patients would bewilling to pay a co-pay for the convenience of doing it at your office, thenyou could actually make money on the testing, especially if you have staffwho have the time to do the visit, follow your protocol, and document thingsappropriately. dtsFrom: Practiceimprovement 1yahoogroups (DOT) com[mailto:Practiceimprovement 1yahoogroups (DOT) com] On Behalf Of LockeSent: Thursday, October 30, 2008 1:22 PMSubject: [Practiceimprovemen t1] INR in Office - options for machineDoes anyone know if there are INR machine companies that basically give youthe machine if you buy the strips, etc, from them?A

couple primary care docs in our office are considering doing a coumadinclinic and wondered about our options.I know some of you are doing INR clinics with the patient having a nursevisit and giving the results and changes at the time of service.How is that going for you?We've already got the Clia waiver, so should be good to go -- just need themachine. Locke, MD

Instant access to the latest most popular FREE games while you browse with the Games Toolbar - Download Now!

November 11, 2008

Myria,

We bill 99364 every 3 months for pts. who prefer to do their INRs at lab. This is totally seperate from their visits. We bill all five patients on the same day every 3 months. It makes it easier to keep track of.

I dont believe medicare is paying it but I recall something that they might start in 2009. We will see.

Our biggest HMO approves $41.

These 5 patients are used to the bill every 3 months - 4 send us a check for $60. The other goes thru the insurance ($41), since we have a contract that says we cant bill patient for covered services.

I only use the $20 telephone management fee for the occasional patient who is usually having the INR done in our office but for some reason needs to have it done at a lab. (typically on vacation out of area)

Again, we dont get rich on this but it takes the psychological burden off of "just swallowing it."

80 to 90 % of our patients are doing their INRs at our office.

Hope this answers your questions.

Mike S.

Thanks for sharing. Do you bill it during the office visit or separtely? What is the actural code? What determines 45 vs 20? If monthly the HMO will pay 20 and if more than that when adjusting the 45? I was thinking I was just going to have to swallow the lost money on these patients.

From: Mike113593aol <Mike113593aol>

Subject: Re: INR in Office - options for machine

To:

Date: Monday, November 10, 2008, 7:46 AM

We do both. Nurse or MD visit - usually 99211, 12, or 13 - for each INR in office.

We also see pt. for regular visits every 3 to 6 months like all who have chronic medical problems. Would typically bill a 99214 or 99215 depending on complexity and time. Of course, if they are due for or situation calls for INR during their follow up or acute visit, we will do it at that time.Most importantly, we are charging $60 q 3 months for coumadin management via telephone (there is a code) for those patients who prefer to have INR drawn at lab. Our largest HMO reimburses about $45. Or $20 if it is an occasional lab draw (like when patient is out of area on vacation.) We would usually bill this as a brief telephone visit. Why spend all that time and incur liability doing it for free?

After an explanation of reason, we have had only one patient put up much of a complaint. She is an artist and travels alot and wrote that we were trying to curtail her independence in her waning years by forcing her to come to our office regularly!! Of course her INR was all over the place and we would spend days trying to track her down to make adjustments. We are happy to let the cardiologist' s office handle her via their "coumadin clinic".

Mike S.

10a.

Re: INR in Office - options for machine

Posted by: " Locke" lockecolorado@ gmail.com familylocke

Sun Nov 9, 2008 2:49 pm (PST)

Thanks .

INR's are irritating.

They are not low risk labs and so require input from the doctor in a timely

matter.

Yes, patients balk at copays to do a nurse visit, but on the other hand, the

second I screw up and the patient strokes, I'm on the hook.

Good points on reimbursement -- and how they suck -- unless you do an actual

visit.

I'll keep that in mind.

Locke, MD

_____

From: Practiceimprovement 1yahoogroups (DOT) com

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

, MD

Sent: Thursday, October 30, 2008 11:52 PM

To: Practiceimprovement 1yahoogroups (DOT) com

Subject: RE: [Practiceimprovemen t1] INR in Office - options for machine