Primary Care Procedures in Women's Health: An International Guide for the Primary Care Setting

© Springer Nature Switzerland AG 2020

C. B. Heath, S. M. Sulik (eds.)Primary Care Procedures in Women's Healthhttps://doi.org/10.1007/978-3-030-28884-6_1

1. Introduction: The Case for Procedures in Primary Care

Cathryn B. Heath¹   and Sandra M. Sulik²  

(1)

Clinical Associate Professor of Family Medicine and Community Health, Robert Wood Johnson Medical School, Medical Director, Rutgers University Student Health, Rutgers University, New Brunswick, NJ, USA

(2)

Medical Director of Primary Care, St. Joseph’s Health, Professor of Family Medicine, Upstate Medical Center, Syracuse, NY, USA

Cathryn B. Heath (Corresponding author)

Email: [email protected]

Sandra M. Sulik

Email: [email protected]

Keywords

Women’s health proceduresAmbulatory clinical proceduresOutpatient procedures

Case Studies

Dr. Jerri Neilsen had a problem. She needed to do a procedure that she had never performed on anyone. There were no specialists available to do it. The nearest specialist was a continent away. What did she do? According to her first-hand account in Ice Bound: A Doctor’s Incredible Battle for Survival at the South Pole, she received instructions by computer and by satellite telephone on how to do a Fine Needle Aspiration (FNA). She and her assistant, who was an emergency medical technician (EMT), practiced the aspiration technique on some fruit, and then they both did an FNA of a breast mass – on Dr. Jerri Neilsen [1].

One of the authors and editors of this book (CBH) was taking care of one of her patients in New Jersey, a state with more specialist physicians per capita than any state in the United States. A woman requested an intrauterine device (IUD) placement, a procedure that the author had not done in several years. She told the patient that she had not done this procedure in quite some time and offered to send her to another physician. The patient’s response was that she preferred her own primary care physician do the procedure, and the patient suggested that the author just read the book and then go ahead. The procedure was successful and was the first of many IUD placements within this physician’s practice in New Jersey.

A patient came in to see one of the other authors and editors of this book (SMS) with symptoms of pressure in her vagina which worsened upon standing. With many health problems, the patient was considered at high risk for major morbidity and mortality from surgery. She came to the author’s office for a pessary fitting, as there were few physicians in town who fit pessaries. SMS successfully treated the woman’s symptoms with a pessary, which avoided major surgery and relieved her urinary incontinence. The grateful woman used the pessary successfully for many years.

Location of Practice

These cases exemplify the necessity for women’s health procedures being done by primary care physicians such as family physicians, internists, pediatricians, and obstetricians/gynecologists and by primary care practitioners such as midwives, advanced nurse practitioners, and physician’s assistants. Although obviously an extreme case, Dr. Neilsen’s case typified a situation in which a woman has difficulty finding a physician to do a basic procedure, a concern common with many women who reside in rural areas. Currently, a significant healthcare disparity exists for women who reside in rural areas. Over 20% of the population of the United States resides in rural areas with rates as low as 26.5 primary care providers/100,000 patients in Mississippi and the rates in Georgia and Texas being only slightly higher (31/100,000 and 33.61/100,000, respectively) [2]. Primary care providers in this study included physicians, physician assistants, and advanced practice nurses.

The scope of practice of rural physicians has by necessity been broad, although the rate of surgical procedures reported by rural physicians in Canada was similar to those who practice in a more urban setting [3]. In a study of Canadian physicians, younger male physicians were more likely than middle-aged to older physicians to do procedures, except for women’s health procedures, which were more likely to be done by women physicians [4]. In a survey of Wisconsin family physicians, Eliason and colleagues noted that 40% of family physicians reported doing skin surgery, flexible sigmoidoscopy, breast cyst aspiration, joint arthrocentesis, and Norplant® (Population Council, New York, NY, and Washington, DC) insertion. Female physicians performed more women’s health procedures than other procedures in any setting [4].

In many instances, access to a specialist for routine procedures is difficult, and, thus, many generalist providers are doing procedures that in more suburban and urban regions are considered reserved for specialists. In a study of colonoscopy in rural communities, family physicians performed colonoscopies on patients with symptoms as well as on patients for screening. Family physicians successfully reached the cecum in 96% of the cases, with an average time of 15.9 min, finding neoplastic polyps in 22% of the patients and cancer in 2.5% of the patients [5].

Continuity of Care: The Medical Home

Patients prefer seeing the same provider and consider seeing the same provider every time they have a health problem as very important [6]. Patients prefer, in many cases, to have procedures done by a practitioner whom they know and trust. For instance, in a study conducted at an inner city clinic, 70% of patients thought it appropriate for their family physicians to do medical abortions. Forty-seven percent thought it appropriate for their family physicians to do first-trimester surgical abortions. Of the women who would personally consider an abortion, 73% preferred to have it done by their family physician, 22% preferred to go to a freestanding abortion clinic, and 5% had no preference [7]. In a survey done by the Kaiser Family Foundation, 54% of obstetricians/gynecologists stated that they would be very or somewhat likely to prescribe mifepristone for medication abortions. Fifty percent of family physicians, nurse practitioners, and physician’s assistants reported interest in prescribing mifepristone. At the time of the survey, only 5% of family physicians currently performed surgical abortions [8].

In 2017, the rate of clinical procedures performed by family physicians at their practice revealed that 31% performed endometrial sampling, 74% performed skin procedures including biopsy and cryotherapy, and 12% performed colposcopy, among a variety of other procedures [9].

Many patients expect their generalist providers to perform common procedures, especially those done in an outpatient setting. Most patients appreciate continuity and find that receiving care (including procedures) from one provider improved the physician–patient relationship [10].

Procedure Training

A number of procedures have become a lost art, making it difficult for patients to access providers who feel comfortable performing these procedures. Physicians in the past have relied on learning procedures in medical school or residency; yet newer, more advanced procedures can only be offered in a postgraduate setting for most practicing physicians.

In medical school, family medicine clerkships provide some basis for learning common women’s health procedures, such as obtaining a Pap smear. In a procedure knowledge survey, Pap smear was the only women’s health procedure that students felt competent of being able to perform independently [11]. In Canada, 91% of physicians reported learning procedures in medical school or in a family medicine residency, whereas only 12.6% learned procedures in clinical practice settings, followed by 6.4% who reported learning procedures in formal skills training. Those in rural practice learned a relatively greater proportion of procedural skills through formal skills training [12].

While the general guidelines for women’s health procedure skills within a family medicine residency [13] have mandatory procedures (endometrial biopsy, Pap smears, wet mount, and KOH prep), some less common procedures are no longer considered mandatory but are recommended (breast cyst aspiration, diaphragm fitting, IUD insertion and removal). Bartholin cyst or abscess treatment and colposcopy are considered elective. There are some significant barriers to teaching and performing office-based procedures, which need to be overcome by residency practices, including assuring adequate volume to be able to teach the procedure, that the appropriate faculty are available, and that there is enough given time in the schedule to be able to perform the procedure [14].

The American Board of Internal Medicine requires as part of its core competency that all internal medicine residents perform Pap smears and endocervical cultures safely and competently [15].

Lack of experience may subvert the physician’s confidence about incorporating procedures into his/her office setting. Sempowski and colleagues did a cross-sectional survey of Canadian family physicians’ provision of minor office procedures and found that of the 108 family physicians and general practitioners in Kingston, Ontario, only 35.4% reported performing endometrial biopsies. The most common reason for not performing a specific procedure was the lack of up-to-date skills [16].

Insurance Coverage

The good news is that many insurance plans across the United States are covering contraceptive procedures more commonly than ever before. Due to the Patient Protection and Affordable Care Act, the United States now mandates that insurances cover the cost of preventive care and contraceptives. However, there are still many women who do not currently have healthcare coverage.

Conclusion

Whatever the rationale, women’s health procedures are in demand, especially in a primary care setting, and are rewarding for both physician and patient alike. No matter where the location of the practice or what type of patient or provider may be involved, generalist providers can offer these procedures as part of their daily practice. All of these procedures are easy to learn, most require minimal equipment, and they offer services that improve women’s health and the range of options for the care that all patients wish to receive from their provider.

Questions

What are the advantages and disadvantages to primary care providers learning procedures?

Which procedures are the easiest and hardest to implement within an office setting?

What are some of the potential barriers to providing outpatient women’s health procedures?

References

1.

Nielsen J, Vollers MA. Ice bound: a doctor’s incredible battle for survival at the South Pole. New York: Hyperion; 2001.

2.

Hing E, Hsiao C. State variability in supply of office-based primary care providers: United States 2012. NCHS data brief, no 151. Hyattsville: National Center for Health Statistics; 2014.

3.

Jaakkimmainen R, Schultz S, Sood P. Office-based procedures among urban and rural family physicians in Ontario. Can Fam Phys. 2012;58(10):E578–E5874.

4.

Eliason BC, Lofton SA, Mark DH. Influence of demographics and profitability on physician selection of family practice procedures. J Fam Pract. 1995;40(3):223–4.

5.

Edwards JK, Norris TE. Colonoscopy in rural communities: can family physicians perform the procedure with safe and efficacious results? J Am Board Fam Pract. 2004;17:353–8.

6.

Baker R, Mainous AG, Gray DP, Love MM. Exploration of the relationship between continuity, trust in regular doctors and patient satisfaction with consultations with family doctors. Scand J Prim Health Care. 2003;21(1):27–32.

7.

Rubin SE, Godfrey E, Gold M. Patient attitudes toward early abortion services in the family medicine clinic. J Am Board Fam Med. 2008;21(2):162–4.

8.

Koenig JD, Tapias MP, Hoff T. Are US health professionals likely to prescribe mifepristone or methotrexate? J Am Med Womens Assoc. 2000;55:155–60.

9.

American Academy of Family Physicians Member Census, December 31, 2017. https://​www.​aafp.​org/​about/​the-aafp/​family-medicine-facts/​table-12(rev).​html. Accessed 13 July 2018.

10.

Haggerty JL, Pineault R, Beaulieu MD, Brunelle Y, Gauthier J, Goulet F, Rodriguez J. Practice features associated with patient-reported accessibility, continuity, and coordination of primary health care. Ann Fam Med. 2008;6:116–23.

11.

Garcia-Rodriguez JA, Dickinson JA, Perez G, Ross D, Au L, Ross S, Babenko O, Johnston I. Procedural knowledge and skills of residents entering Canadian Family Medicine Programs in Alberta. Fam Med. 2018;50(1):10–21.

12.

Crutcher RA, Szafran O, Woloschuk W, Chaytors RG, Topps DA, Humphries PW, Norton PG. Where Canadian family physicians learn procedural skills. Fam Med. 2005;37(7):491–5.

13.

Edwards FD, Frey KA. The future of residency education: implementing a competency-based educational model. Fam Med. 2007;39(2):116–25.

14.

Langner S, Deffenbacher B, Nagle J, Khodeaee M. Barriers and methods to improve office-based procedural training in a family medicine residency. J Med Educ. 2016;7:158–9.

15.

American Board of Internal Medicine, policies and procedures for certification. https://​www.​abim.​org/​~/​media/​ABIM%20​Public/​Files/​pdf/​publications/​certification-guides/​policies-and-procedures.​pdf. Accessed online Apr 2018.

16.

Sempowski IP, Rungi AA, Seguin R. A cross sectional survey of urban Canadian family physicians’ provision of minor office procedures. BMC Fam Pract. 2006;7:18.

© Springer Nature Switzerland AG 2020

C. B. Heath, S. M. Sulik (eds.)Primary Care Procedures in Women's Healthhttps://doi.org/10.1007/978-3-030-28884-6_2

2. Coding, Billing, and Reimbursement for Procedures

Cathryn B. Heath¹  

(1)

Clinical Associate Professor of Family Medicine and Community Health, Robert Wood Johnson Medical School, Medical Director, Rutgers University Student Health, Rutgers University, New Brunswick, NJ, USA

Cathryn B. Heath

Email: [email protected]

Keywords

Gynecologic procedure codingGynecologic procedure billingGynecologic procedure reimbursement

Introduction

Coding, billing, and reimbursement are an integral part of the procedures performed in today’s modern medical office. Gone are the days when one could learn a procedure and then just expect payment for services rendered. Performing the actual procedure is only part of the process. At times, billing and coding can be even more complicated and time-consuming than actually performing the procedure itself. Appropriate billing with concomitant reimbursement is very satisfying and can gradually change the emphasis and tenor of a clinician’s practice. It is crucial that, prior to instituting a new office procedure, the clinician and the billing staff review the proper billing and coding to ensure that payment will occur.

Procedure Coding

As seen in the various procedure chapters in this book, included within each chapter are appropriate codes that must be compatible with the procedures discussed and shown. If a clinician is seeing a patient for diagnoses other than just the procedure, each diagnosis and procedure needs to be coded separately. For instance, if a patient is being seen for a gynecologic exam and requests that her intrauterine device (IUD) be removed, the clinician would code the appropriate health maintenance code for the exam, use a -25 modifier, and then code for the IUD removal [1]. If the patient prefers to return another day for the IUD removal, one would only code for the actual procedure on the IUD removal visit.

Many procedures have global codes. Thus, if a procedure such as a Bartholin’s gland excision requires a second visit for a recheck, the recheck is considered part of the original global procedure code and would not be billed as a second office visit. Similarly, if there are sutures being removed for a procedure done in the office, the suture removal should be covered in the global fee. There are some exceptions to the rule: for example, one can bill separately for a visit to review and discuss treatment options of colposcopy pathology.

Coding compatibility with the procedure is essential to ensure payment. Medicare’s website (http://​www.​cms.​gov) is an excellent place to start [2]. Healthcare Common Procedure Coding System (HCPCS) has two levels. Level I coding is used to code for the procedure itself, associated with the appropriate ICD-10 code. There are stipulations for which ICD-10 (International Classification of Diseases, 10th Revision, Centers for Disease Control and Prevention) codes will be covered by private payers and CMS for a specific procedure. Level II HCPCS allows for coding for products and supplies.

It is imperative to have someone in your financial office who is prepared to review rejected claims, particularly for procedures, and who can pursue the reasons for rejection. As billing improves, rejected claims decrease in number. Coding also can be improved and facilitated by using specific coding software, websites, or standardized forms, some of which may even be accessed by either an electronic medical record or a handheld electronic device. There are many coding and billing software packages available in the market that will help promote effective coding.

Documentation of Procedures

All procedures need appropriate notes written by the clinician. Size and location of excised lesions should be documented, as reimbursement is determined by size, location, number of lesions removed, and the pathology of the lesion (benign versus malignant). Billing should be submitted based not only on the size of the lesion but also on the size of the margins. For instance, if a 1 cm lesion is removed using a margin of 0.2 cm on each side, the size would be considered 1.4 cm [3]. Follow-up should be clearly stated in order to document whether a subsequent visit should be considered part of the procedure.

Coding and billing for skin procedures is further complicated by the specific pathologic diagnosis of the lesion itself. For instance, coding for removal of a benign versus malignant lesion may be difficult until the biopsy results have returned to the office, which may be anywhere from 10 to 14 days after the date the actual procedure is performed. However, removal of a malignancy is generally reimbursed at an average of two to three times the amount of the removal of a benign lesion. Thus, in some instances in which the CPT® (AMA, Chicago, IL) code may be dramatically changed by the pathology results, it may be advisable to hold billing the particular procedure until the pathology report returns and is reviewed.

One can also attempt to bill for an unsuccessful procedure, though the likelihood of being reimbursed is much less [4]. Coding needs to be specific; for instance, if a procedure fails due to anatomic reasons, a -52 code is used as a failed procedure. If the procedure fails due to concern over a patient’s well-being, as she has had severe pain or vasovagal symptom, it is considered a discontinued procedure and is coded as a -53. The payer will need to know the extent of what was done; attaching a copy of the office note to the claim will usually suffice. Some insurances do pay for an attempted procedure, while others do not.

Insurance Company Coverage

Medical procedures are highly scrutinized by insurance companies due to the expense of the procedure itself. Some insurance require prior authorization for procedures, which may include submitting prior office notes, labs, or radiology reports to substantiate the need for the actual procedure [5]. This varies nationally by region and by the policy negotiated by the patient’s employer. The Patient Protection and Affordable Care Act, signed into law in 2010, currently requires that contraceptives be covered by insurance companies, including long-acting reversible contraceptives (LARCs). Medicaid coverage of LARCs is variable. It is best to check with the insurance company prior to performing the procedure.

The list of billable procedures may not be standardized, even by commercial insurance vendors. It is vital to obtain the region’s billable procedure list from each one of the insurance companies that are accepted by an office. If a given procedure is not present on the billable list, the clinician may need to negotiate with the insurance company for inclusion of that particular procedure.

Durable Medical Goods

Durable goods, such as IUDs, may be stocked by an office if they are used on a frequent basis. It is always best to check with a patient’s insurance company prior to performing a procedure and, if possible, to arrange with that insurance company to assist with the provision of a device. If a patient cannot or will not wait for that to occur, it is always important to have the patient sign an Advance Beneficiary Notice (ABN) stating that she is willing to pay for the procedure and the durable goods prior to performing the procedure. If the office is providing the device, the clinician needs to bill the specific HCPCS or J code associated with the device as well as billing the code for the procedure itself. Not to do so will mean that the office will absorb the cost of a very expensive device. Many offices order the device when the patient comes in for a consultative visit prior to the procedure. The IUD is then sent to the office in the patient’s name; when it is received, the patient is called so that insertion can be scheduled. In this case, the provider will bill the procedure code but not bill for the device. There are organizations that will assist women advocating with their insurance to get one, such as the National Women’s Law Center Cover her project [6].

Charity Care Procedures

Charity care services also may be available for procedures such as IUD insertion or implantable devices. For instance, the Arch Foundation was established as a not-for-profit institution to help low-income women who have no insurance coverage for the levonorgestrel intrauterine systems manufactured by Bayer. Primary Care residencies who participate in charity care programs for teaching learners how to insert or implant contraceptive devices may in some cases be able to access devices from manufacturers. Physician preceptors who oversee learners must be present for the entire procedure in order to bill for the procedure.

Cosmetic Surgery Billing

Most cosmetic surgery is not covered by insurance companies and is considered an out-of-pocket expense for the patient. Most clinicians who provide cosmetic surgery will stipulate that the patient pays prior to the actual procedure being performed. It is best to do a consultation prior to the procedure and to clearly provide the price of each procedure both verbally and in writing. Having the patient sign an ABN prior to the procedure is helpful.

Summary

Appropriate coding and billing improves women’s access to important health procedures, as practitioners are more likely to continue doing procedures for which they can be paid. Due to the coding specificity, tracking payment and improving the process of payment are relatively easy tasks for any clinician’s practice. Familiarizing oneself and one’s billing staff with coding for procedures by type of procedure and by type of payment by specific insurance company will increase the likelihood of payment, thus rewarding the clinician for providing services that are requested by the patient or necessary for good clinical care.

Questions for Learners

What are the pros and cons of stocking devices within an office setting?

How would you streamline the authorization process?

References

1.

Hughes C. Multiple procedures at the same visit. Fam Pract Manag. 2007;14(7):24–5.

2.

HCPCS coding questions. Centers for Medicare and Medicaid Services, Baltimore, MD. https://​www.​cms.​gov/​Medicare/​Coding/​MedHCPCSGenInfo/​index.​html. Accessed 12 July 2018.

3.

Fox G, McCann L. Twelve errors to avoid in coding skin procedures. Fam Pract Manag. 2013;20(1):11–6.

4.

LARC coding. Long Acting Reversible Contraceptives. University of California in San Francisco. https://​larcprogram.​ucsf.​edu/​coding. Accessed 12 July 2018.

5.

Reichman M. Managed care administrative tasks: cutting the red tape. Fam Pract Manag. 2006;13(9):32.

6.

Cover her. National Women’s Law Center, Washington D.C. https://​nwlc.​org/​coverher/​. Accessed 12 July 2018.

Additional Resource

Websites

http://​www.​archfoundation.​com/​.

The Arch Foundation: http://​www.​archfoundation.​com.

https://​larcprogram.​ucsf.​edu/​coding.

© Springer Nature Switzerland AG 2020

C. B. Heath, S. M. Sulik (eds.)Primary Care Procedures in Women's Healthhttps://doi.org/10.1007/978-3-030-28884-6_3

3. Legal Aspects of Office-Based Women’s Health Procedures

David E. Kolva¹, ²  

(1)

Department of Family Medicine, SUNY Upstate Medical Center, Syracuse, NY, USA

(2)

Family Medicine Residency Program, St. Joseph’s Health, Syracuse, NY, USA

David E. Kolva

Email: [email protected]

Keywords

Medicolegal aspects of proceduresCulture of safetyPolicies and proceduresMedical consent for procedures

Introduction

As primary care practitioners face increasing liability risk in this litigious society, careful planning and timely consultation with your competent legal advisor are critically important to reduce your exposure to lawsuits or misconduct sanctions. The conviction of former Michigan State University, US Olympic Committee, and US Gymnastics national team physician Dr. Larry Jassar on several hundred sexual assault charges in 2018 has sent shock waves throughout the medicolegal policy-making world. There will be future far-reaching investigations (and litigation) into the failures of these institutions to protect young female athletes from predation and abuse. The facts will help shape how to correctly respond to accusations in the future. It is imperative that all practitioners who provide health care to females go beyond the institutional written policies and fully adopt a culture of safety to avoid invasions of patient privacy or physical boundary violations.

Since the regulation of medical practice is largely an individual state activity, and laws vary widely by locality, this chapter is not intended to provide personal legal advice. When your practice makes decisions about new policies or procedures, they should be clearly recorded in a practice policy and procedure manual. A user-friendly manual, in print or electronic form, will standardize policy and procedure throughout a medical practice and facilitate training of new employees. The clinician leader of the practice must be the role model for establishing a safe culture to protect and respect every female patient.

Office Physical Plant Concerns

Local zoning laws regulate the use of the office building premises for provision of medical services. If your existing practice location is in complete compliance with local zoning law requirements, none of the procedures described in this book should require additional special permits or variances since they fall into the category of usual medical diagnostic and therapeutic services for licensed physicians.

If you are adding colposcopy or electrosurgery services to your practice, you should consult with an electrician to evaluate your electrical service requirements. Equipment manufacturers will provide the detailed specifications to ensure safe operation.

The decision whether to purchase or lease your new equipment has important tax implications. Consultation with your accountant is mandatory before any large practice expense. For example, the cost of a new colposcopy suite may easily surpass 15,000 dollars. The cost of necessary physical plant electrical, plumbing, and storage improvements should be budgeted carefully. Remember to review your office/business property insurance policy to include the new equipment and leasehold improvements.

O.S.H.A. Concerns

In 2001, the federal Occupational Safety and Health Administration (OSHA ) substantially revised the 1991 compliance standards for employers to prevent employees’ exposure to bloodborne pathogens [1]. Your practice must have an exposure control plan to reflect these standards, and it must be reviewed and updated at least once a year. The employer is responsible for staff training and compliance as well as proper documentation of these activities. Practitioners and assistants who perform these women’s health procedures should have serological documented immunity to hepatitis B. The practice must have a written protocol that clearly outlines proper handling, storage, and disposal of sharps (needles and blades), toxic chemicals (acetic acid, Lugol’s and Monsel’s solutions), and regulated medical waste. Personal protective equipment and emergency eyewash stations must be provided by the employer.

The practice must create engineering controls that allow for the proper ventilation of waste nitrous oxide gas from certain cryosurgical instruments if this equipment is used for cryosurgery of cervical or vulvar lesions. Similarly, a smoke evacuation system should be available for electrosurgical procedures to minimize aerosolized tissue inhalation .

Promotion of Services

If the practitioner is providing outpatient women’s health procedures for patients outside of the practice’s enrolled panel on a referral basis from other practitioners, then state and federal anti-kickback laws prevail. These laws, Anti-Kickback Statute (42 U.S §1320a-7b(b)) and Physician Self-Referral Law (Stark) (42 U.S.C. § 1395nn), prohibit self-referrals, fee-splitting arrangements, and other types of activity between business entities [2]. You must consult an attorney who is knowledgeable with this technical area of the law before promoting or advertising your services to patients outside of your group practice.

Individual States regulate the scope and content of advertisement of physician’s services. Fraudulent or misleading advertisement is considered professional misconduct in most states and may negate your malpractice insurance coverage for these services if results are guaranteed or falsely solicited [3].

Credentialing Concerns

While surgery performed in facilities licensed under state Public Health Laws (such as hospitals or ambulatory surgery centers) is subject to regulatory standards