ysis of an ISOMP ’ s effects on the workflow and billing activities within that provider ’ s practice was undertaken .
METHODS
An intentional practice change was implemented by a single practitioner within a rural family medicine practice beginning in March 2014 . One day per month was designated specifically for monitoring and managing patients on opioids . Electronic health records were searched for all patients on opioids for non-malignant pain , who were scheduled every three months . All required aspects of opioid monitoring were conducted in these visits including the following : patient diversion risk , pill counts , urine drug screening , and review of the state-controlled substance database . Control of patient pain was assessed with standardized tests for pain rating , effect on function , and depression ( Table 1 ). 8 Violations of the controlled substance contract was dealt with on a case-by-case basis favoring education over terminating the doctor-patient relationship . The decision to wean opiates was a shared decisionmaking process and patients were allowed to restart opiates and the monitoring protocol if desired .
A retrospective review of the financial data and billing practices on the previously studied 19-month ISOMP 8 was conducted and compared to a matched directly preceding 19-month period . Data was extracted from the institution ’ s financial and patient encounter records within the electronic medical record for global and daily productivity . The data was de-identified during collection and measured for the number of patient encounters , work relative value units ( RVU ), no-show visits , financial charges , reimbursement , and frequency of Evaluation and Management ( EM ) codes . The study did not receive any funding and was approved by the Marshall University Institutional Review Board ( IRB # 720850 ).
RESULTS
The specific day each month during which ISOMP was conducted was compared to like data before the protocol ( Table 2 ). The average number of patients seen on the ISOMP day decreased by -24.82 % over baseline and the no-show rate decreased by
TABLE 1 : Components of an Intentional Structured Opiate Monitoring Protocol Visit Subjective
Description of all pain complaints Quantification of medication regimen Review of set pain control and functional goals Documentation of most recent testing Pain Contract Verification Review patient documents * Chronic Pain Symptoms Review of Symptoms Form Zung Depression Scale : evaluation for depressive symptoms Brief Pain Inventory - short form : evaluation of pain and its effect on life Disability Rating Scale : evaluation of functional disability Screener and Opioid Assessment for Patients with Pain - revised ( SOAPP-R ): opioid abuse risk evaluation
Past Medical History ( of pathology affected by opioid use ) Social History Objective Exam
Pertinent physical exam findings Time documentation
Testing
Pill count Urine drug screen collection Board of Pharmacy evaluation
Assessment
Fully classifying pathology causing pain Describing functionality
Plan
Decision to continue , increase , or wean opiates Discussion of adjunctive medications for pain management Discussion of adjunctive therapies for pain management Evaluation for referrals Evaluation of need for further imaging Discussion and literature about proper disposal of medication Discussion about potential for drug abuse
* Completed by the patient while waiting for the physician
-72.75 %. The use of the time-based 99215 code rose dramatically . The average total work RVU for this day remained stable with a -2.16 % change .
All patient encounters for the 19 months prior to and during ISOMP were analyzed ( Table 3 ). During the ISOMP , the total number of work RVU increased by + 7.73 % despite a -7.38 % decrease in encounters . The average number of patient encounters per day declined by -2.75 %. The average number of no-show visits was reduced by -12.14 %. The average work RVU , charges , and reimbursement increased by + 16.37 %, + 14.80 %, and + 13.06 % respectively .
Table 4 depicts the 17 subjects who chose to remain on opioids ( Group A ). Total encounters were reduced -6.41 % from baseline . This net decrease occurred due to increases of + 20.51 % in opioid management visits coupled with a decrease of -33.33 % in acute and chronic care . Work RVU for this group increased by + 42.95 % during ISOMP driven by a + 111.59 % increase in RVU linked to opioid management , which translated to a + 52.78 % increase per encounter .
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