Procedure clinic prep

Making the Most of Procedure Clinic

• A few days before the scheduled clinic, look at the schedule and review the upcoming procedures.

  • Patients are listed under “GME Procedure Room” (not your name)

    • Once patients arrive on the day of, you may move them to your schedule

• Most likely the patients scheduled are not your clinic patients, so you may not have seen the lesion, abnormal result, etc they are coming in for. Look at the note for the visit when the referral to the procedure clinic was placed. There may be photos of the lesion to help you start thinking about what you want to do (punch biopsy, shave biopsy, etc), if applicable.

• Some things to consider

  • Colpo: Is a colpo indicated? Review the pap results. Remember to consider pap history, not only the most recent pap result. Ensure the abnormal pap result is on the Problem list and the pap history is in the overview.

  • Removal of lesions: are they in a safe place to be removed (is it overlying a major blood vessel or nerve)? Too large to be removed in the office?

  • Circumcision: Will the baby be 30 days old or less on the day of the procedure? Did they receive Vitamin K?

• Review procedure videos on the residency google website. https://sites.google.com/site/fsufmrp/clinic-resources/procedures

• Remember you have a Nexplanon practice kit at home! Practice insertion and removal if it’s been a while.

• Be sure you have a note template you like for each procedure.

  • Dr. Coghill has lots of nice ones and there are some generic ones used throughout the system you may like

• Reviewing orders and billing

  • To bill for procedures, go to Wrap Up, scroll down to Charge Capture and search for the procedure you performed. You may also need to go to the MAR and input the medications administered (IUD, Nexplanon, joint injections). Epic Tip Sheets are also very helpful!

  • For Nexplanon and IUD insertions: You will need the NDC, Lot numbers, and expiration dates from the packaging. Remember to keep the packaging or the sticker insert with that information to do the billing/MAR.

  • If the patient comes in and you do a lot of counseling before the procedure (ex: help them decide if they want an IUD vs Nexplanon before placing it) you will bill for both the counseling visit and the procedure (99213- 25 modifier plus the procedure code for the insertion). Plus of course, the GC modifier indicating that your attending was in the room for the procedure.

  • If they already knew what they wanted, you do a no-charge visit and JUST bill for the procedure itself.