COVID-19 and urology: What you can do

Dr. Rosevear is a urologist in community practice in Colorado Springs, CO. Urology Times blogs present opinions, advice, and news from urologists and other urology professionals. Opinions expressed by bloggers are their own, and do not necessarily reflect the views of Urology Times or its parent company, MJH Life Sciences.

I’m not sure anyone truly understands what is going on right now with this novel coronavirus or how the situation will play out. From a medical standpoint, while as a urologist I am confident that I can put a Foley catheter in anyone, the last time I managed someone in the ICU was in residency. I’m not sure if I have the skillset to help those who become truly sick from this disease, although the Italians are reportedly drafting urologists and orthopedists to help run ICUs, given the scope of the problems they are encountering.

Hence my mind drifted to what I can do to prevent the spread of the disease. Computer modeling shows that aggressive social distancing, or reducing the interactions that all of us have on a regular basis, can be the most effective way to prevent the spread of the disease. This Washington Post article has a great illustration of modeling no action versus quarantine versus limited and aggressive social distancing. Aggressive social distancing prevents overwhelming case load and wins by a mile. It is just tough to implement and enforce.

Yes, most likely everyone in the world in the next year will contract and test positive for COVID-19. Our job at this point is to “flatten the curve” of infection rate to the point where our hospital system is not overwhelmed with potentially 500,000 ICU patients in the next month, instead of over the next year.

We also have to understand that we have an office to run and employees to pay. Therein lies the inherent compromise. Some might argue that we completely should shut down our clinics and send our employees home. I understand that, but I don’t know if it is realistic in the long run.

On the other hand, people have both truly emergent urologic needs (torsion, Fournier’s, septic stone) as well as urgent needs that cannot be handled over the phone (clogged catheter, painful but not septic stone). And what about our cancer patients? If we simply defer all NCCN recommended surveillances (cystoscopies and imaging tests, for example) until once the virus is contained, have we caused harm?

Further, what about my employees? While I’m thrilled that the government passed a law that all employers need to pay their employees who don’t come in because they are sick, if this virus event lasts for more than a few months, I’m not sure if I can do that without at least some revenue continuing to come in.

What can we do today? Below is what my office is doing; while it’s not perfect, it’s a start. I highly recommend that if any other office has an idea about “best practices,” please share them by emailing urology_times@mmhgroup.com. Just like best practices for medicine need to be shared, so should best practices for running an office.

Screening. Follow CDC guidelines for personal, staff and patient screening, referral and disinfection.

Cash flow. This is not the time to pay out bonuses. In reality, this is not even the time to pay out full salaries to most doctors. Most of our staff have significantly fewer financial reserves than we do and we should prioritize, where possible, paying them. The good news is that, assuming CMS and other payers don’t stop processing payments, we should not see a decline in revenue for a few weeks. This will give us an opportunity to conserve capital and prepare for the revenue slowdown. My office is also prioritizing bills and asking our creditors for understanding given the extraordinary circumstances. Lastly, if you don’t have a line of credit, now is the time to reach out to your local banker and start one.

Telehealth. In the past, CMS had placed numerous restrictions on who could use telehealth and in what circumstances that greatly limited the technology to rural patients. Those restrictions have been lifted for the most part. My office is going to start reaching out to our non-urgent patients and use this technology where possible. I included below some basic guidance on the codes that can be used, but please talk to your billers on how best to use this.

G2012-Brief communication technology-based service, e.g., virtual check-in, by a physician or other qualified health care professional who can report evaluation and management services, provided to an established patient, not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion.

G2010-Remote evaluation of recorded video and/or images submitted by an established patient (e.g., store and forward), including interpretation with follow-up with the patient within 24 business hours, not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment.

If your office has video capabilities to communicate with patients (virtual face to face), you can bill your typical E&M code 99211–99215. You must state the service was provided via telehealth in your notes.

99441-Telephone evaluation and management service provided by a physician to an established patient, parent, or guardian not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion

99442-Telephone evaluation and management service provided by a physician to an established patient, parent, or guardian not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 11-20 minutes of medical discussion

99443-Telephone evaluation and management service provided by a physician to an established patient, parent, or guardian not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 21-30 minutes of medical discussion.

Triage patients. Patients with fevers or coughs should not be outside of their house (unless they are on the way to the ER), let alone in your office. We have a sign on our front door that in no uncertain terms tells patients with those conditions as well as any possible recent exposure to the virus to turn around and not even enter. A urologist’s office is not the location where patients with COVID-19 should be triaged. We also borrowed the phone triage, below, from a friend of a friend who works at Johns Hopkins in a pediatric pulmonary clinic. Clearly, the verbiage and the phone numbers needs to be modified, but it’s a great way to start. We believe by transitioning all routine follow-up visits to telehealth visits, delaying all non-urgent new patient visits (while bothersome, no one dies from urinary leakage or ED), and leaving the clinic open with a skeleton staff, we can best serve our patients by keeping those patients who have to be seen out of the ERs.

Elective surgery. As you likely heard, the Surgeon General has advised all hospitals to start canceling and rescheduling elective surgeries. It’s tough to argue against that, given the risk of exposure to medical staff and the need to preserve resources. On the other hand, cancer is cancer and I’m not sure if I believe that all cases should be canceled. Delaying treatment of a large renal mass or a bladder cancer can only be safely done for so long before changing outcomes.

Staffing. If you are going to keep your office open on a minimal basis with the goal of trying to keep urgent patients out of the ER, how do you do it? Check-out staff and some check-in staff can certainly work from home as long as they have remote access. Tough decisions need to be made on a case-by-case basis about which staff to have on premises. Do you allow older staff or staff with baseline medical problems to not come in at all because of their increased risk from the disease, realizing that will increase the burden of exposure on the other staff? Further, given that most schools and daycares are closing, some of your younger staff may have problems with daycare if they have small children at home. Communication with your staff to understand their needs and concerns and to explain your goals is vital.

Supplies. Masks and hand sanitizers may very well run short depending on the length of this crisis. While it is too late now to stockpile a supply, we are reaching out to the suppliers to ensure that we receive adequate supplies while realizing that there are certainly clinics that will need more of these supplies than we do.

Urologists. What about us? Urologists are one of the oldest of all specialties. And yet patients are going to get sick during this period and require our expert care. Do we ask the younger doctors to take on a higher percentage of call or hospital work to allow the older doctors more opportunity to isolate? What about those doctors with sick family members at home? Should they also be given the opportunity to step back from medicine? Tough questions that I do not have the answer to.

Keep yourself busy. Let’s face it, most of us are going to be spending a lot of time away from the office over the next few weeks. Don’t spend your day surfing the web or watching CNN. Be productive. Take this opportunity to spend time with your kids, read a book, write a book, do that house project you’ve been putting off.

I hope that by sharing some of the steps that my office is using to address this pandemic that best practices can be quickly and efficiently shared throughout the urology community.