Have you ever found yourself busily attending to a patient's acute problem when all of a sudden a nagging voice inside your head reminds you that you haven't yet asked the patient about that needed flu shot, Pap smear, tetanus shot or other preventive service? Although health plans and government agencies are often quick to remind us of our preventive failures, many physicians shy away from prevention, viewing it as a can of worms they simply don't have time to open. The uncertainties of preventive care coding and reimbursement can also complicate matters. (See “Getting paid for prevention.”)
One tactic that can help in these situations is to enter the exam room or hospital room with at least one preventive goal in mind and be prepared to “sell” it, using a few well-applied strategies:
GETTING PAID FOR PREVENTION
Getting paid for preventive services depends on correct coding. Here's how to code four common types of preventive visits.
A standard preventive E/M visit. Use a CPT preventive medicine service code (99381-99397) plus the appropriate ICD-9 code.
A preventive E/M visit with a problem-oriented service. Use a CPT preventive medicine service code (99381-99397) plus the appropriate E/M code (99201-99215) with modifier 25 attached to show that the services were significant and separate. Link the appropriate ICD-9 code(s) to each CPT code to help distinguish the services. Note that not all payers will reimburse for both preventive and problem-oriented services on the same date.
A preventive visit for a Medicare patient. Medicare does not reimburse for CPT's preventive medicine services codes, but it does cover certain screening services. (See “What's New in Medicare Preventive Benefits,” FPM, February 2007.) Submit the appropriate HCPCS and ICD-9 codes to Medicare for the covered screening services and assign the appropriate CPT preventive medicine services code to any other preventive service provided, charging the patient for that portion of the visit.
A preventive counseling visit. Counseling that occurs during a preventive medicine encounter is considered to be part of the preventive medicine services codes. When preventive counseling is the focus of a separate visit, it should be reported with the preventive counseling codes (99401-99412).
For more information see “Making Sense of Preventive Medicine Coding,” FPM, April 2004.
1. Prepare a one-liner. Have a short speech prepared in your mind so you can advocate for the needed intervention. Consider this clinical scenario: You are in your clinic in early October, and thanks to your good planning, you actually have a decent supply of influenza vaccine. Your nurse is collecting a patient's vital signs and briefly asks about the flu vaccine. The patient, who has diabetes and chronic heart failure, hasn't had a flu shot but declines the service, and the nurse notes that under the chief complaint.
As you enter the exam room, you say hello to the patient and exchange pleasantries, and then – before you launch into the chief complaint – you say:
“My nurse noted you do not want the flu vaccine this year. I strongly recommend this shot, especially for a person like you. Your sugar levels and weak heart can lessen your ability to fight infection, and getting the flu could lead to a long hospital stay. If you'd like, we can give you the shot at the end of your visit today.”
You can tailor your pitch to the situation, addressing typical reasons patients refuse the service (fear of needles, uneasiness about side effects, cost concerns, etc.). The key is simply that you have a spiel and are ready to use it. Start by focusing on just one preventive area that seems to fall through the cracks in your practice. Some examples include meningococcal vaccination, aspirin therapy to prevent myocardial infarction, exercise promotion, compliance with statin therapy and tetanus vaccination.
2. Know your customer. Use your knowledge of the patient and his or her social, family and cultural circumstances to craft the most effective prevention message. Family physicians have a distinct advantage here since we often see the entire family. For example, if a 12-year-old patient needs the new tetanus/pertussis combo booster, you might describe the importance of protecting adolescents from waning immunity. But if the patient also has a newborn sibling at home, you can make your spiel more effective by pointing out that pertussis in a newborn would be a medical nightmare and the 12-year-old fits within the prime demographic for pertussis carriers.
3. Know your product. Knowledgeable salespeople keep useful product facts and figures fresh in their mind. You can use this technique to promote preventive strategies as well. With vaccines, don't focus on administration details or recommended age ranges. Instead, focus on physiologic benefits. Note that the flu vaccine covers not one but three influenza strains. Point out that the pneumonia vaccine often stops some of the most resistant strains of streptococcus pneumonia. Focus on the well-proven benefit of statins for heart attack and stroke prevention.
4. Be passionate. Passion speaks volumes and can greatly aid your delivery of a preventive one-liner. If you really believe in the preventive service you're touting, the patient is more likely to believe in it too. Even if you don't have a passion for prevention, you can usually get enthusiastic about something you hate. For example, if you dread sending your patients to dialysis, advocate for microalbuminuria screenings in your patients who have diabetes. Or if you can't bear the idea of having to explain a colposcopy to a 14-year-old patient and her mother, then direct your energy toward increasing HPV vaccination in adolescent women.
5. Hone your delivery. If a one-liner feels awkward, fine tune your approach to your natural comfort level. If you like statistics, incorporate some disease reduction rates. If you prefer a more emotional approach, share an anecdote to make your point.
For example, one Sunday afternoon, I spent 30 minutes in an urgent care setting removing more than 60 sutures from the facial wounds and abrasions of an 11-year-old girl who was injured while driving a four-wheeler without a helmet. She had initially been treated by an ENT and plastic surgery team two hours away but needed some follow-up between surgery appointments. The story of her scarred face is a quick but poignant tale for my “parental supervision/safety one-liner” during well-child physicals. While this measure won't prevent all injuries, it helps me feel as though I am truly practicing the art of medicine.
Try these strategies for yourself, and you may wind up selling your patients on preventive measures that could significantly improve their health and well-being.