I’ve often written about the low salary of infectious disease (ID) physicians as compared to other medical specialities. Much of this is due to ours being a cognitive field where we think more than we do and to the payment incentive plan being designed to reward volume and procedures more so than medical decision thinking. Here I discuss some of the unreimbursed care that we provide that is of great value to patients, hospitals, and society. Let me know your thoughts and if there is indeed a workable a CPT code for the work listed below, please share.
Phone Calls As Unreimbursed Care
- Calls to the microbiology lab at a different hospital to obtain culture results from the past x months for a patient now under our care
- All the effort and time talking to other physicians to convince them to de-escalate antibiotics or to take a patient to the operating room for source control
- Consulting with other ID colleagues about an unusual case (emails and list-serve submissions included)
- OPAT trouble-shooting (see below)
- Calls to the state health department or to the CDC to report a communicable disease, or to obtain permission to perform testing for a rare disease, or to obtain a release for a drug not yet marketed
- Calls to inpatient pharmacy to get non-formulary medications ordered ASAP; calls to the ambulatory pharmacy to make sure a patient’s medications are covered
- Phone calls here and phone calls there
History Taking
There’s a joke in medicine that if you want a good discharge summary for a patient with a complicated or prolonged hospital stay obtain an infectious disease consultation. We dissect and biopsy the medical record so well that other physicians just copy and paste our notes.
We often have to dig through records to find relevant microbiology data particularly susceptibilities (see call outside microbiology lab above) or to piece together all the HIV resistance mutations a patient may have in order to provide appropriate antibiotic or antiretroviral options. Gratifying detective work? Yes. But unreimbursed care all the same.
Lab Interpretation
An EKG technician takes an EKG and the cardiologist reads it. In addition to their consultation on the patient, the cardiologist can also bill for the interpretation of the EKG. It’s their skill.
Meanwhile, there is no mechanism for coding for and thus being reimbursed for the interpretation of lab results. This is true across the board. Interpreting complex HIV genotypes, confusing Lyme labs, equally confusing EBV labs which in many cases shouldn’t have been ordered are specific skills of the ID physician that constitute unreimbursed care.
Microbiology & Radiology Rounds
Yes, the microbiology lab provides identification and interpretation of cultures, and yes the radiologist provides an interpretation of an imaging. But which ID physician hasn’t called down to microbiology (or send-out, or specimen-processing) to make sure a particular test is performed or to chase after a specimen sitting in chemistry or histology so that it can be used in microbiology for an as yet not ordered test before it’s contaminated?
Which ID physician hasn’t met a nurse or technician right after specimen procurement to make sure that it was properly collected and preserved (or kept fresh)? How many times have we reviewed an image with the radiologist that leads to a change in the read and thus in the differential diagnosis or treatment plan? When we sit with the pathologist to look at slides with them, what is that called?
Wound Care
Some ID physicians are wound doctors. The rest of us are antibiotic doctors for wounds. We may not be the ones debriding them (reimbursable), but we cannot make an assessment of a wound if we don’t unwrap then rewrap the dressing (unreimbursable). And. That. Takes. Time. Not inclusive of the “procedure” of taking a wound swab for culture since no-one else has bothered to do so. Not inclusive of cleaning the wound before re-wrapping the dressing.
Everything related to OPAT
I once had a patient family member get irate with me for suggesting outpatient parenteral antibiotic therapy (OPAT) for their loved one. They felt that it was a money-making scheme on my part. Nothing could be further from the truth.
Many ID physicians do not run their own infusion centers. We send patients home with home care or we send them to an infusion center. We do not get a cut of whatever the home care agency, OPAT pharmacy, or infusion center gets reimbursed for their care.
No, we simply have the responsibility of choosing the antibiotic, setting up the order for it and the orders for routine bloodwork, coordinating start time with patient, pharmacy, social work; and answering phone calls from the home nurse, the patient, and the outpatient pharmacist throughout the course of therapy (2 – 8 weeks if not more). Calls regarding a change in patient status or abnormal labs that necessitate a change in the antibiotic order or calls regarding interruptions of care. Let’s not even talk about the patients who go to a rehabilitation facility instead of home whose labs and rehab team we have to chase down.
At a previous job, we required patients on OPAT to have weekly office visits. In one regard this was a way to capture care already being provided in a reimbursable manner. Needless to say, some patients were not happy to come in to see us “just to talk about their labs”. At least when they go to their surgeon’s office for follow-up something is done, eg. stitch removal. Sigh. They have no clue the magnitude of the work being done behind the scenes to keep their OPAT going. All of which is our liability.
All this to say that for the vast majority of the time when the ID physician recommends a course of intravenous antibiotics at home, it’s not because it’s a benefit to us it’s because it’s what is best for the patient. It’s best for the hospital who can admit a new patient into that bed. It’s best for the patient’s insurance company since home care is cheaper than hospital care.
Curbsides as Unreimbursed Care
Need I say more?
Final Thoughts
I know it’s impossible to quantify and code for everything that we do as part of the provision of care. But it would be nice for the system to recognise the immense value provided by cognitive medical specialists like infectious disease physicians and just reimburse us more than they currently do per patient encounter to capture all of the above work.
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