Home Forums Discussions Feedback and Recommendations Dinamap interface$

I heard that a Dinamap or similar vital signs device can save my nurses a lot of time. Is it hard to interface these to AC somehow? I'm not interested in an $8K Welch Allyn 'solution.' The old vital signs monitors seem to have some sort of serial port on the back. I can only imagine buying a single used device under $500 since I'm in family medicine.

Kevin,
Hey those W/A employees are our patients and that pays the bills around here...Just kidding (lol). W/A is only about 20-30 minutes away from here in Skinny @$$ as we like to say. Hey I officiate their kids on the weekends so the jokes on them, right? "Don't like the New Standard; there's the box." Yeah their stuff is extremely expensive. Besides temp and B/P what other things can this thing do??? Pulse O2 and the like? Anything else? Just wondering if it is really worth the price of admission. But saved time is always nice...And who's disposables does it use???

Has anyone else heard about the new "improved" W/A CleanSpecs? Goodness knows what they actually did to the things, but now these too are more expensive. And on a procedure and codes that half those no good carriers want to pay for... It's only cervical cancer. The federal gov't only started all of CLIA because of bad issues surrounding PAP smears. I gather you all get bundled on your women's wellcare visits too. The CPE is the only thing paid for while most of them lop off the G & Q codes. If you don't care to pay a licensed professional to do it then let Harry down at the quicklube collect your pap. "Hey lady get on the Lift....Watch your step...Going up...."

But it's like everything else in this new soon to be mandated high tech stuff. Everybody is asking for it, everybody claims to want it (at least the carriers and the gov't do) but who wants to pay for it??? You are right to want to not pay for it. People pay for what they value and they don't pay for what they don't. Let them start to pay, then we'll all do something about it. I guess that means most people no longer apperciate PCP's...That's very sad. Look at my "Cornell" posting.
Good Night and Good Luck,
Paul

I have refused to let them bundle my Paps with other services. If I do a well exam on a woman but she goes to a GYN for her PAPs, the GYN gets paid. So, I explain to the patient that their insurance will not pay for me to do both exams the same day and I make them come back another time for their PAP. It means another COPAY for the patient but,hey, it's their insurance, let them complain to Wall Street. In fact, so many of my patients complained to one specific carrier which is very big here that the carrier finally quit bundling. I still maintain the only way we will hope to change things is to get the consumers fired up about insurance companies. Just because an insurance company has their "rules" does not mean we have to play by them. We must be creative.

Leslie

I have refused to let them bundle my Paps with other services. If I do a well exam on a woman but she goes to a GYN for her PAPs, the GYN gets paid. So, I explain to the patient that their insurance will not pay for me to do both exams the same day and I make them come back another time for their PAP. It means another COPAY for the patient but,hey, it's their insurance, let them complain to Wall Street. In fact, so many of my patients complained to one specific carrier which is very big here that the carrier finally quit bundling. I still maintain the only way we will hope to change things is to get the consumers fired up about insurance companies. Just because an insurance company has their "rules" does not mean we have to play by them. We must be creative.

Leslie

Hockey--Man what were you smokin' yesterday? Your post has me roflmao. I ran into the gyn around the block coming out of the subway station yesterday. She has an automatic BP machine because she caught more than one of her MAs faking blood pressures. And even when they don't fake them, they are often "not trustworthy" 'cause those MA schools don't really teach or train--they just take money. We've had our own trouble with MAs and blood pressure. "Gee, an awful lot of patients this week have bp of 120/80--just like in the text book."

We received an automatic unit as a prize (made by OMRON I think) but even the MAs complained that it was inaccurate.

If I could find an automatic one that is accurate and reasonably priced, I'd get it just to save Vicky the time of taking the bp. But they seem kind of overpriced--as if there is an extra "Doctor's office markup" being added.

Leslie, we do the same thing. Vicky actually stopped doing PNPs (Pelvic n' Paps) but when we did them, we did them as a separate visit from the general physical because the insurance companies wanted to bundle them (they cover general physicals here). But some companies only cover one "preventive" visit a year so a woman couldn't get a general physical and a PnP in 2 visits and be covered for both. We have had some angry patients because instead of blaming their insurance company they BLAME US! And those unneccessary tests we did. Well, I guess screening for syphillis, hepatitis, heart and thyroid problems are unneccessary if the results are negative. That doesn't help the patient we screened that tested postive for syphillis. Or hep b or c. And we have had surprize positives on all.

We also have a list of insurers that wont pay for her to address and issue on the same visit as the general physical. I give these patients a handout explaining it to them, so it the extra issue isnt something REALLY MINOR AND QUICK like acne, there wont be one of those discussions tying Vicky (or me) up.

Oh my goodness...I've been trying to figure out this whole thing regarding getting paid for paps. I do lots of them and I'm to the point of not doing them anymore - the visits get denied left and right.

What's really ironic...is women over the age of 40 are the visits that get denied most often! And guess what? That's where I find the most pathology (non-cervical)! I'm not talking medicare here either - in which women can't have annual exams unless they are high risk.

If we have a coding expert on pap's here, I wish they'd speak up and tell me how to get them paid, what codes are used and when, etc. I'm sure I won't be the only one forever grateful!

Tired of getting tricked and no treats!

For us, Medicare is about the only entity that will pay separately for pap (Q0091). However, reimbursement for this is a joke and if I cover another topic as an E&M the same day, it gets bundled together.

We used to use an S cpt code for the well woman exam with the V icd code for PnP visits. This keeps it separate from the V70.0 an 99395 preventive visit.

S0610 for new patient Annual gyn exam, S0612 established patient. If they still wont pay, I'd say refer them to a gyn and tell them that their insurance company doesnt cover this service unless done by a gyn.

Hi Gang,

In our office, it depends on the patient, we're not all that formal or uptight about it. If they have a lot of GYN issues AND need a general checkup, one is the checkup, the other is an E&M code with a diagnosis. Separate days, separate copays.

You have to put it in the context of the patient. If they have hypertension and hyperlipidemia, make their checkup the E&M visit - you ARE managing their hypertension and hyperlipidemia that visit - and then do their pap and breast exam as the 9939x code.

If its just a general well-woman exam on a patient who is "low maintenance", we just do the PAP as part of the checkup.. takes about 5 extra minutes. You're still doing everything else, why not throw in the PAP with that visit as well? Doesn't add all that much to our cost, and the patients appreciate that by going to a Family Doc, they can get it all done under one roof with one visit. They appreciate it and tell their friends - its good for business.

Generally its the "train wrecks" we split into two visits.


The WA specs are OK.. although I REALLY wish that they didn't discontinue the other ones. The new ones take their old lights just fine, and our cost did't look to be TOO much different, but I LIKED the old ones better. The new wide handle isn't as easy to handle as the old ones. Whatever. Is typical WA now. They used to be a better company back when W and A were alive. We're going to see a lot more of their "discontinued" products being totally unsupported in the future. In the past you could get parts or repair services for ANYTHING that they made. I now have a Tympanometer and a Videopath video endoscopy system which they no longer support, no longer repair, and no longer stock parts for. I bought a spare bulb for the light source for the endoscopy system because they only have a few left, and when they're gone they're gone. Nice.

We have a couple of Critikon BP monitors which we bought on e-bay for abuot $50 / each. If I can find the protocol to talk to 'em I can better advise Jon about the possibility of talking to them. My thinking though is just put a computer or laptop wherever the vitals are being taken, and let them punch in the numbers. You will find that an interface will take just as much time to find the patient and then import the vitals as just typing 'em in is.

If you don't trust your MA's to get the BP right manually, get one of the wrist BP cuffs for about $50. We've compared the numbers against our Critikon monitors and they're accurate, cheap and digital - hard to "fake". If the numbers don't seem reasonable, can be checked manually by the doc - which only happens rarely.

Regards,

V.

Vinny,
So it's not just me. The new vaginal speculums don't fit very well with the lighting system. I will refuse to pay hundreds of dollar for a flashlight that will fit the new plastic speculums. I'm looking if anyone manufactures to old speculums or I could create an rubber stopper so that I can retrofit to use the new W/A vaginal speculums.

So, Bert, how about a workaround for the vaginal specs?

This automatic Omron bp machine gives results all over the place. Left us w/ a bad taste in our mouths. She's getting resigned to just taking them herself or buy a more expensive bp machine that at least is pretty accurate.

There is no work-around - the light thinie goes in turned 90 degrees from how it USED to go in. There are two grooves, and the flat ears on the light can go into either groove. The old light fits just fine - it's just that the wider handle part doesn't feel as comfortable to the hand when being used - I think it gets in the way.

Call me if you're still having problems getting it to fit - takes a little to figure out, as it isn't obvious.

V.

We've had good luck with the Omron's when they're used correctly, and they're easy to use wrong (hand HAS to be on the shoulder or on the table at heart level, etc). Still, hit e-bay - we have FOUR of the Criticon monitors we bought, and the most we paid for a strait BP was $50. The weird one I have with a pulse-ox built in was like $100.

V.

I had no idea what you guys were talking about until my new WA specs arrived yesterday. Sigh.

Re eBay...I LOVE it! I puchase many supplies from them. Amazing that I can get a some perfectly good, new and used supplies and equipment at half of what I can get at various supply houses.

Barbara,

I wouldn't buy a vital sign system from WA.. I get the impression based on experience with them that they're not going to stand behind their product for more than about 5 years if you're lucky. In the old days they supported things much longer. If you're a hospital with deep pockets, who uses equipment heavily, then maybe a 5 year life is OK for a vital sign system, but for a private doc's office where equipment is lightly used, maybe this doesn't make good economic sense. Add to that that WA gear is NOT CHEAP, I'd look elsewhere for this equipment.

Now OTOSCOPES - THAT's a different story! THEM the only brand I'll touch is WA. Other people get into the market, loose interest, and leave, and suddenly everything you own is "obsolete" (HELLO!!! HEINE USA?? CAN YOU HEAR MEEEE????)

Regards,

V.

Ok, the Omrons are easy to use wrong. I suspected that was the problem, but I had (have) limited time to try to see what was going on. Maybe they didn't have the person put the hand on the shoulder because someone didn't read the directions.

There's a bunch of nice Criticon units on e-bay this week, one with pulse ox with thirteen hours left on it, no bids, starting bid $195. No reason to give WA a gazillion bucks for this.

V.

GYN Codes,
If we are doing a CPE on the same day we are billing an appropriate 99395, 6, or 7 or what have you. Then we 25 modifier it for separate and distinct as AETNA wants you to as laid out in their settlement, because they will pay for G0101 the actual breast and pelvic exam! Yes many a medical society fought in court for a number of codes and that is one of them. But they will bundle out, Q0091 for the collection of the pap, but we do bill it anyway for all to see their dirty ways.

We are getting resigned to the fact of two separate visits, which is really sexism against the hard working moms or employeed women and their docs who care for them. My female doc gets a lot more of these to do than a similar male doc, right? he gets time to do another quick sick visit while my wife has to wait for the patient to get into a robe, do all of the two exams, collect the darn sample, and then wait for the patient to get dressed again, this is discrimination. I wonder what policy would be if it were an annual penis exam, no chitt.

And as we understand it, Medicare doesn't pay for physicals, but they don't care if you code and bill for all these services on the same day. No coding conflicts. It's balance bill the patient for the CPE that they don't cover. Isn't that great? All these elderly and disabled patients on Medicare and they won't cover an annual well exam. Tell me this country isn't upside down and in a toilet.

Now this little solo office and it's big mouth PM (me!) got one of the larger SCHIPS carriers here in NYS to cover and pay for all of these on the same day! I just won millions of dollars of unpaided claims for thousands of PCP's, GYN's and their paients in the state of NY by myself last year. Even after the lawyers at MSSNY told me to shove off and didn't want to hear about it. Don't you think MSSNY owes my wife an free lifetime membeship seeing what we by ourselves have done???

My arguement was sound and logical. First off here in NYS we have the "women's health and wellness act" because for years these SOB's wouldn't cover such things. So I told them it is our position that they are in violation of the act. You can't go from not covering and not paying to supposedly now covering but still not paying for them (G&Q). Also I used the sexism line.

Plus I used the Mr. Spock like logic of this. Three patients. One goes to their PCP and has all her care done on the same day, CPE with G & Q. They'll only pay for the CPE even though we have done more. Second patient comes in on two days a day apart at the same doctor's office and then they will pay for all 3 codes. Third patient has the CPE in the morning at her PCP's office and then, taking the entire day off from work, she goes to her GYN and has him/her perform G & Q and again the carrier will pay for all codes. So they are penalizing the PCP who takes good care of her patients, is considerate of their time and performs all needed services on the same day. And now Fidelis Care had a number of meetings and now they will pay for all of these performed on the same day. Now obviously we actually have to come thru and deserve such and every now and again for various reasons, such is not appropriate, and so we properly don't submit all codes, which again was another part of my arguement. For example if the patient does have G & Q performed elsewhere or on a different day (she doesn't feel good, wrong part of her cycle) then obviously it is wrong to submit them. And so we don't. I mean doesn't this seem like better and more accurate coding??? Isn't that what they all want out of you folks?

BTW, CCI Edits who is supposed to be a fairly accurate and neutral third party in coding and billing has "no billing and coding conflicts for all of these being performed and submitted for the same day on the same bill. So how come such inappropriate bundling is never prossecuted as a form of insurance fraud, just as our submitting inappropriate unbundling would be in the reverse. Why does my gov't not spend it money and resources agressively protecting patients and providers from such obvious fraud???

Lastly, we should never forget what these exams really are. They are a real form of screening for certain forms of cancer! I'm old enough to remember the messed up false negative paps that lead to the CLIA. The monster of breast cancer has haunted my family since I can remember as a young child. I remember watching my paternal grandmother suffer as she wasted away from late treated breast cancer. It is very personal to me. These fights can not be won on their ballfield of codes and insurance. They must be fought to be won on the our field on right and wrong and they are almost always wrong.

Every time a doc performs a breast and pelvic and collects a PAP, they are screening for potential cancer and they are collecting real cytology, which also requires a chain of custody. Also such docs are exposing themselves to the ever slight but real risk of legal issues. Some of these patients will develop cancer or other changes while under your care, the numbers can't be denyed. Some patients will, whether appropriate or not (yeah, you helped find the darn thing so they could attend to it) will lash out at their provider in such a situation. For all this extra care and risk, don't you guys at least deserve to be paid a bit extra for the services? And yes, the fees the majors pay are not in keeping with their usual percentages of Medicare Fee Schedule. But PCP' are treated on an equal footing to their others in the field, right?

And those W/A speculums cost a few bucks a piece my friends and now they cost even more with the down sizing of the box. And don't forget the paper robe or laundry service too. You probably drop $3-$5 bucks on each one of these when you add it all up. But you're not entitled to some extra compensation. Oh yeah, and you've got to properly disposed of that speculum too don't forget.

Yeah, yeah, I'm a PM, but someone's got to watch the store around here, while the gov't ties you docs up in knots.

How about a surcharge for new W/A speculums? Reduced fee if recycled ones are used. (it's a joke...or is it?)
Thanks for the post, though. I have always bundled gyn exam with CPE. We'll try billing separately to see how that would work. So, what CPT code do you use for gyn exam (breast and pap smear)? Is the Q and G codes OK to use for private insurance or is it only for Medicare?
What codes do gynecologists use?

G0101 and Q0091. Those are good codes here. Now many of our carriers are not as enlightened as we would like. I see it as "billing and charging equally", it's not my problem or in our control that some carriers are not under NYS law but ERISA instead and so they can get away without paying or covering many of the NYS required healthcare and preventive care. And many of the ones that bundle somehow are doing the old switch-a-roo that I mentioned before. They have some how went from "not covering and not paying" for such things as women's wellcare to "now they claim they are covering it", it's in their plans and on the patients benefits print outs on the websites, but yet they are "still not paying for it". Pretty neat trick really. Only in the business of orwellian insurance company new speak can one do and say such a thing and actually get away with it. Simply AMAZING...

But that is why I went to our state medical society only to be treated like a pain in the butt child and a lowly PM of a worthless female, solo FP. Nancy is not some $500K a year downstate NYC specialist. Even in medicine I feel like PCP's are treated like the small businesses in for capital one ads. What's in your wallet? (don't use capital one though they don't report great credit use of paying your balance in full every month to the credit agencies so you get "no credit" for being really good)

I think PCP's need to form a separate break off organization that only deals with the real day to day issues of primary care because even your own societies don't get it. Some radical fringe group that wants reform for both patients and docs. Internal Med, Peds and FP's all together telling the AMA, all the state Medical Societies and all your individual ones where to shove it. You missed the boat years ago before all this got way too crazy and now it is probably too late, but we're not staying on your leaking, sinking ship...BYE!

But back to GYN visits. We code almost all of them the same because that is what we do on those that we code. It's a danm long visit here for Nancy with a lot to do and a lot to chart. And all those supplies we mentioned. $5 discount to those who bring their own W/A speculums... We have our Depo patients fill an Rx at the pharmacy because so many carriers won't even pay what it costs us to get it on the open market. That is why we are not carrying the new HPV vaccine either. At over $120 (more when it first came out if I remember) a pop times three and to get paid not even cost by many of the carriers is more than I will stand. When that was first released the local blues wanted to pay us like $85! Now I wonder how cheap they would have been if the vaccine kept men's shlongs from turning green and falling off? Sorry this stuff pisses me off so.. As a dad, a son, a husband and the PM of a female provider with a 70% female panel. Just unreal.

Just who are and who creates that average wholesale list that most of the carriers throw in our faces for the cost of vaccines and the like anyway? They are not from this planet obviously because your average office can't find most of the products on their lists anywhere near the prices that they are claiming exsist. Didn't you all know that now you are also in the business of insuring lives??? I thought we were on the other side of the street here. But we are not allowed to charge for the covering of those lives at prevailing market rates like the carriers are...
I've got too much chitt to do here so let me run,
Paul

Hi Paul,

I don't sweat doing the pap and breast exam as part of a woman's annual physical. We just make sure that we separate any E&M from the physical, and address it as a separate visit.

We don't stock Depo-provera, and we bill a 99212, a pregnancy test, and an injection fee, and code the med with a price of zero when we bill it. The shot is given by one of the docs and the decision whether to give it or not is low complexity, and rates an office visit. I ran this by a friend who is a "Certified Coder" (whatever the hell THAT is) and she agrees its appropriate.

We stock the HPV vaccine, and all of our carriers cover it at just about our cost. Most will pay more if you provide proof of the cost (ie a copy of the invoice) with the claim. Any carrier that reimburses below our cost - their patients get an Rx for their vaccines, and an explanation of how and why their insurance company sucks. I then let THEM do the legwork.

GHI sent us a memo that we're supposed to start stocking Depo-Provera.. I called our rep about what amount it would be reimbursed at - and she still hasn't gotten back to me. If I don't know UP FRONT that our cost is covered, then the patients will continue to get an Rx for the med, and if their insurance won't pay for the Rx at the pharmacy, they're welcome to pay for the med out of pocket at the pharmacy. Heck, a dose of Depo-Provera is about $50 - for 3 months of coverage. Cheap!

I think, though, we need to be more active in our local medical societies, rather than be upset they're missing the boat. They're missing the boat because the only people who set policy are people with agendas contrary to our own. I'm a delegate to the annual house of delegates meeting, and I generally go to other meetings. I am NOT the quiet wallflower type. Many of the docs in Saratoga think I'm a pain in the A**, but I've also had many positive comments by other more quiet docs who appreciate the radical idiots being put in their place.

Paul, we've all just got to keep up the good fight, is all.

V.

Hockey, that's why we no longer do PnPs. You pretty much explained why Vicky no longer does them for me, thank you. But we had a nice one the other day. A women went to her gyn for her "well woman exam." Found a breast lump. Did the Gyn refer her to a breast surgeon? NOoooooo! Refered her to a PCP (us) presumbably so she doesn't have to generate the referral and verify that she went to see the surgeon.

We usually get $125 for the Gardisil vaccine, plus the administration fee. I have determined that this is not worth giving. It a total of $133 or so reimbursement this causes "Cash Flow Problems" for the practice. I think we should write a Rx for it, let the patient pick it up, and then only charge for administering it. Vicky likes to give the vaccines so that she can turn the visit into more by asking about some other problems that the patient may have been having. I think its better to skip the vaccine and just have a different patient who is sick come in.

Medicare only pays for one "introduction to Medicare" physical, but since the patient will have a deductible the patient pays for it anyway.

We also code the 99385 and address another issue by using a -25 modifier w/the 99203 or whatever. This is exactly how the CPT book says it should be done and Medicare honors this. But coding by the CPT book seems to required of doctors, while paying by this coding seems to be an "option" for the 3rd party payers. So Aetna, GHI, and HIP of NY will pay this way, while BCBS/Wellpoint, Cigna, UHC, Oxford, and Healthnet won't. HIP and GHI make the patients pay an additional copay as if it was a second visit. And the patients argue about it too. They say "we didnt address that" we say "Huh? I wrote you an Rx and/or referred you to a specialist."