Great insight above. I have never been able to figure these situations out. My scenario is more often like this:
A middle aged man has HTN, Diabetes Mellitus type II, COPD, GERD, Obesity, Hyperlipidemia, and Degenerative Disc Disease of the whole spine with chronic incapacitating pain in his back - mostly in the lower back, with radiation of the pain as well as tingling and burning sensations in his feet.
He has gone through 2 separate surgical procedures for his spine separated by 3 years. He does not like how pain medications (NSAIDs, Cox-2 inhibitors, opioids, tramadol, lyrica etc.) make him lose his alertness to varying degrees when he is given enough to decrease the pain level to 'tolerable'.
So, he comes to me about 3 times a month, usually in severe pain, unable to find a tolerable posture, let alone any kind of relief in the pain that he scales at 8-10/10.
I examine him thoroughly - looking for his overall health status with respect to nutrition and hydration, side effects of his medications, complications from his systemic illnesses, the level of his discomfort, the state of his weight, blood pressure, lipids, Skin, bladder, CNS, Psych, and, of course, the muskuloskeletal system. I put him on a lumbar traction device, start him on 250 ml of saline with the following added to the bag: Ketorolac 60 mg, Orphenadrine 60 mg, Infusible Multivitamins, and Magnesium Sulfate 12 mEq.
While the intravenous infusion is going, and after the traction session is finished (usually 20 minutes), the patient continues to be monitored with vital signs every 15 minutes, and a brief examination of the mentation and pain level plus mobility every 20 minutes.
This patient ends up spending almost 180-200 minutes in the office: the first 30 minutes or so going over the CC/HOPI, Medication Reconciliation, 14-point ROS, physical examination, review of tests and X-Rays at times, and then discussions with the patient and his wife about the recommended plan of care.
The rest of the time is spent in delivering the treatments and monitoring the patient.
This patient has been very compliant, never asking for more meds or higher dosages, only occasionally ending up in the ER: perhaps once every 10 weeks or so, usually when his pain gets unbearable before his scheduled appointment with me and the schedule is just impossible for us to fit in a 3hour appointment. This is in contrast to previous fortnightly visits to the ER.
What is the best way to code situations like this? It would become essential for us to do this right because I am starting to see more such situations in my office, usually related to pain management. But sometimes intravenous fluids fir dehydration and / or IVPB for antibiotics, Nebulizer treatments, wound care, and sometimes just counseling and coordination of care, for instance the end of life issues, or comprehensive dietary education involving reviews of diet diaries, and other such patient-education matters.
So, a clearer understanding of the various types of prolonged visit scenarios will be immensely helpful.
Thanks in advance,
Just another old-fashioned family doc.