Patient Forms

Surgery Scheduling

We have created this web page to assist you in learning the process of scheduling surgery or office procedures, verifying benefits, and determining what your out of pocket expenses will be for your upcoming surgery or procedure.

Considering Surgery? Have it in Our Office!

We have increased our In Office Surgery Program!

Why?

* Lower costs for the patient
* Time savings for the patient and the Doctors * Reduced anesthesia
* Better patient tolerance
* Faster recovery time
* Procedure performed in the comfort of our office

Who?

* Ablations – Novasure
* Essure Birth Control
* LEEPS
* Minor procedures/biopsies requiring anesthesia

When?

Usually we perform these procedures one Friday each month, but can be done in the hospital other days

How?

Encompass Medical brings everything you and the doctor needs for an in office surgery experience. At a cost savings to you, their fee is only $325 (not covered by insurance), and not a percentage of your hospital fees (For example if you have a 90/10 plan, you are responsible for 10% of all fees, so if a hospital charges $10,000 for an ablation, your portion to the hospital alone would be $1000). See Insurance Information below for detailed insurance payment information.

Our doctors want you to be as comfortable as possible and use anesthesia for all ablations and Essure procedures

THINGS TO DO TO GET READY FOR SURGERY

1. Call your insurance company with the codes given below and ask the questions below to determine if your surgery/office procedure is covered and how much it will cost you. Pay close attention to your deductible! (We will call your insurance company also, but it is always good to have us both call)

2. Have all tests ordered by your doctor to ensure you are a candidate for surgery, and that insurance will approve your surgery/procedure. (Please see below for tests required)

3. Have your consult appointment with your doctor to discuss your test results, and all your treatment options, and finalize surgery plans. If you are not already on the surgery schedule, at this appointment time it is best to have the ideal days you are available to have your surgery.

4. Call our surgery scheduler at 817-424-3112 ext 8 to coordinate a surgery/procedure date. It takes 2-3 days to coordinate with hospital, anesthesia and assistant surgeons.

INSURANCE INFORMATION

If you are considering surgery, this section will give you the common procedures codes for surgeries we perform, so you can contact your insurance company to see if it is a covered benefit. You will need to ask your insurance company several questions:

Is the procedure code a covered benefit?

Is it covered at 100% or what is your percentage that you are required to pay. (this percentage will be paid to all involved in your care, for example if you owe 10%, then that is 10% to our office, 10% to the hospital, 10% to anesthesia, 10% to pathology). We can give you the allowable for our portion, you will need to contact the hospital and anesthesia office for information on their charges. (Baylor Grapevine 817-424-4545, Harris Methodist Southlake Center 817-748-8700, Pinnacle Anesthesia 972-233-1999)

Do you have a deductible to meet? What is it and how much of it has been met?

Do you have a facility co-pay?

If financially you are able to have the surgery, there are several clinical tests they need to be done in our office or ordered by our office to get your surgery approved. We will list those tests below. In general, you will need to have all required tests, and then a consult at our office with your doctor to discuss all the results, and develop your treatment plan. It is good to come to the consult appointment with some idea of dates you would like for your surgery. In general we use Tuesday’s and Friday’s as our blocked time for surgeries, although occasionally we can accommodate you on different days. We schedule hysterectomies and all in-patient surgeries on the 1st, 3rd and 5th Tuesday and Friday’s are for our outpatient procedures.

Procedure Codes for Surgery/Office Procedures & Tests Required for that Surgery

In Office or Hospital Endometrial Ablation (Novasure) CPT code 58563

* CBC, recent sonogram (within 6 months), recent pelvic exam, current pap smear, possible endometrial biopsy

In Office or Hospital Essure Tubal Ligation CPT code 58565

* CBC and pregnancy test

Total Laproscopic Hysterectomy (TLH) CPT code 58570

Total Abdominal Hysterectomy CPT code 58150

* CBC, sonogram, possible endometrial biopsy, recent pelvic exam, current pap smear

Laparoscopic Assisted Vaginal Hysterectomy (LAVH) CPT code 58550

* CBC, sonogram, possible endometrial biopsy, recent pelvic exam, current pap smear

Laparoscopic Supracervical Hysterectomy (LASH) CPT code 58544

* CBC, sonogram, possible endometrial biopsy, recent pelvic exam, current pap smear

Laparoscopic Bilateral Tubal Ligation (Tubes Tied) CPT code 58670 (Cowen) 58671 (Neal)

* CBC and pregnancy test

Removal of Ovarian Cyst (Laparascopy) 58661

* CBC

Hysteroscopy CPT code 58558

* CBC

Trans Obturator Sling (Bladder Repair) CPT code 57288

* CBC, urodynamic testing

Laser of Cervix CPT code 57513

* CBC the day of surgery

Hymenotomy CPT code 56700

* CBC the day of surgery

Hysterosalpingogram (HSG) CPT code 58340

Office Procedures

Colposcopy (Abnormal Pap Smear Evaluation) CPT code 57454

LEEP (Abnormal Pap Smear Treatment) CPT code 57522

Mirena IUD J7302 Insertion 58300 *For IUD device, deductibles typically apply

Paragard IUD J7300 Insertion 58300 *For IUD device, deductibles typically apply

Implanon J7307 Insertion 11981 or 11975 *For device, deductibles typically apply

RECOVERY

Abdominal Hysterectomy usually requires 2 nights in the hospital, and a 6 week recovery. You will not be allowed to drive for 2 weeks.

Vaginal Hysterectomy usually requires 1-2 nights in the hospital and a 4-6 week recovery. You will not be allowed to drive for 2 weeks.

Supracervical hysterectomy usually requires an overnight stay (23 hrs observation) and has a 2-4 week recovery. You will not be allowed to drive for 2 weeks.

Bladder surgery usually requires a 1 night stay in the hospital and a 2-3 week recovery.

Tubal ligations, hysteroscopy, laparoscopy and ablations are done on an outpatient basis, and have a 1-2 day recovery.

Surgery Checklist

1. Have initial appointment with your doctor
2. Call your insurance company and verify your benefits and your out of pocket expenses
3. Have all required clinical testing ordered
4. Have consult appointment to discuss all results of testing and establish treatment plan. At this time, please tell your doctor several different dates that you are available for surgery. He will then give your chart to our surgery scheduler.
5. Contact the surgery scheduler to confirm you are able to proceed with surgery. Kim can be reached at 817-424-3112 ext 8 or at www.surgery@grapevineob.com.
6. Give surgery coordinator 2-3 days to coordinate requested dates with hospital, assistant surgeons, and contact insurance company for verification and pre-certification.

Surgery coordinator will contact you with surgery time and date, location, and out of pocket expenses for proposed surgery. We send an email and/or a letter with all information.

Fees to our office are due 48 hours prior to your surgery time. You may pay in full with cash, check or credit card, or use our Online Payment Plan to satisfy your surgery charges to our office (www.grapevineob.com).

Pre Op Instructions – ALL SURGERIES

Nothing to eat or drink after midnight the night before your surgery No water, gum, candy or smoking on the morning of your surgery (you will be cancelled by anesthesia if you eat,drink, smoke or have candy the morning of your surgery) Report to the hospital at your designated time, 1 1/2 hours prior to your surgery time.
Avoid aspirin, and ibuprofen (Motrin) 2 weeks prior to your surgery

Prescription Renewals

Prescription renewals are most efficiently handled through our practice’s messaging system which is available on this website. Please try to anticipate your need for prescription refills by notifying the office at least 48 hours in advance or by advising your physician of your needs during regularly scheduled office visits. If you have not been seen in this practice within the past twelve months, it is our policy that you make an appointment to renew your medication.

Laboratory, Radiology and Hospital Charges

Due to the requirements of some insurance companies or the nature of certain laboratory studies, your lab tests may be sent from our office to a reference laboratory. Reference laboratories are independent of our practice and will bill separately for their services. For all laboratory, radiology and hospital charges, it is the patient’s responsibility to determine if these providers are covered by your individual plan. Most will bill your insurance directly. If you have questions about bills and cannot resolve them with insurance company or other provider directly, please talk to a member of our billing staff.

Contacting Our Office

Contacting Our Office

We ask that you use our website to contact our office for all routine matters such as appointment scheduling or requests, prescription refill requests, billing questions and other non-urgent questions. We will make every effort to respond within one day. If you have not seen a physician recently, we ask that you make an appointment for all medical problems. If you need to cancel a scheduled appointment, please give our office 24 hours notice. If you need to call our office, our staff is available from 8:30 a.m. to 4:30 p.m. Monday through Thursday and 8:30 to 12:00 on Friday. We are at lunch from 12:30 to 1:30.

In the event of a life-threatening emergency, please go directly to the nearest emergency room, (by ambulance if appropriate), and advise the staff that you are our patient. If you are having a medical problem after hours or on Weekends and Holidays, please call the regular office number. A doctor will then be contacted through the answering service.

Transferring of Records

You will need to request in writing if you want to have copies of your records sent to another doctor or organization. You will need to include the specific dates of service, medical information requested and the reason for this request. Your signed request for release of records will need to be received before records are sent. We use a copying service, Photostat, which copies records weekly. There is a $32.50 charge for copies of records sent to the patient.

Updating Your Information

Patients are responsible for providing accurate, up-to-date information. You can update your insurance, personal and medical information from within “My Health Record” in this website. As you may have several physicians, this information can change without the treating doctor being aware of these changes. We ask that you login prior to any scheduled appointment to keep this information current.

Returned Check Policy

There is a fee of $20 for any check returned by the bank.

Cancellation Policy

If you need to cancel your appointment with us, we ask that you give at least 24 hours notice. For appointments that are cancelled within less than 24 hours or for “no show” appointments, you will be assessed a $10 cancellation fee. This will be payable prior to your next visit.

Acknowledgement of Online Interaction Policy

PATIENT ACKNOWLEDGEMENT AND CONSENT TO ONLINE INTERACTION POLICIES

I wish to use Internet-based communications, registration and other Internet-based modes of interaction to facilitate my receipt of health care from this practice.

Benefits and Risks

I understand that the benefits of Online Interaction include being able to take advantage of the expertise of a physician who may not be physically available to provide health care, and access to sources of information suggested by my own physician. I understand that there are potential risks associated with receiving health care through Online Interaction, including for example, timeliness of the interactions and the inability of a physician to give me a complete physical examination. Consequently, there is a risk that a physician may not be able to determine the proper diagnosis and treatment based upon Online Interaction. I understand that the practice specifically reserves the right to withhold conclusions of diagnosis and/ or recommendations for treatment based upon information obtained via Online Interaction in the absence of an in-person encounter, and that I am not to interpret any comments of my physician(s) or the staff as a diagnosis or specific treatment instruction under those conditions, unless my personal physician specifically indicates that I should. I understand that general information to which my physician(s) may refer me, or that which may be available on their Web sites, is not to be used for purposes of self-diagnosis or self-treatment, and to the extent that I do so I release my physician(s) and the practice and hold them harmless.

Confidentiality and Security of Information

I understand that all state and federal rules and regulations governing confidentiality of my medical records and access to my Personally Identifiable Health Information (including my ability to obtain copies of my records) will apply to services provided through Online Interaction and to the electronic transmission and storage of my Personally Identifiable Health Information.
I understand that my physician(s) and the practice will not give any images or information that identifies me and was obtained through Online Interaction to other entities without my consent unless permitted to do so under applicable laws or unless required to do so as part of a legal action. I have read and understand the privacy policy of the practice as published on its website.
I understand that for purposes of Online Interaction the practice uses programs and technical services provided by the following third parties:
1. athenahealth, inc. for billing and claims management.
2. TimeTrade Systems Inc. for online appointment scheduling.
3. Waiting Room Solutions, LLC for website registration and secure messaging.
I understand that when I conduct Online Interaction with the practice.s staff, I am subject to the privacy, confidentiality, and information security policies of those third parties and I have had the opportunity to review said policies.
I understand that despite best efforts of all involved parties, there remains some amount of risk of inappropriate disclosure of my personal information, and I agree to hold the practice harmless for such disclosures when they occur as the result of acts or omissions of third parties.

Use of .Electronic Mail.

I understand and agree that I am not to use the secure messaging service in emergency or other time-critical situations. I understand that the practice and its physicians discourage the use of standard e-mail for communicating about personal health issues, because standard e-mail is not a secure communications mechanism and does not provide structured forms of communication. Instead, the practice uses a secure, healthcare-oriented messaging service from Waiting Room Solutions, LLC. I understand that while I should not use regular e-mail to communicate to my physician and his/ her staff about personal health matters, standard e-mail may be used by the practice for purposes such as sending me notification of new messages that have been sent to my secure mailbox, or non- personal types of communications such as informing me of changes to office policies

I understand and agree that I am to use appropriate language and tone in my messages and other Online Interaction, and in particular I am to avoid any language that abuses, mocks, belittles, or attacks the recipient or is in any way libelous to third parties. According to the Privacy Act of 1974 and court rulings, employers generally have the legal right to access any e- mail received or sent by a person at work. I understand generally that I should not communicate with the practice (including my physician(s) and staff, and including via standard e-mail) using computers or networks of my employer.
I understand that online communications alone are not sufficient for proper medical care. I understand that my physician may refuse to continue online discussion of a condition when he or she believes an in-person encounter is appropriate. I understand that in no case should I expect my physician to deliver a conclusion of diagnosis, a recommendation for treatment, or a prognosis regarding a complaint or symptom for which I have not been seen in person, or regarding a condition for which I have not been seen in person within the previous 20 days.
I understand that I am to keep copies of messages received from my physician. I understand that my physician will retain copies of our communications within my medical record.
I understand that if my username and password is obtained by another individual, including an unauthorized family member, I am to notify the practice immediately and at the earliest opportunity should return to the practice or its website to establish a new username and password.

Physician May Discontinue the Online Relationship

I understand that my physician may discontinue his or her Online Interaction with me under any circumstance in which he or she believes that I have used Online Interaction in a manner that is inconsistent with his or her policies as stated herein. I understand that I will be notified of such termination of Online Interaction

Ownership of Information

I understand that neither the practice nor my physician(s) make any claim of legal ownership of the electronic information that is exchanged via Online Interaction and stored by third- party providers of online services. I also understand that there are no current conclusions of law that would hold that the information is legally owned by me, by the practice, my physician(s), or the vendors of the online services used to create and store the information. However, I understand that I do have rights of access to the information, and rights of refusal to disclosures of the information.

Consent

I hereby consent to obtaining some aspects of my health care from the practice using Internet-based communications or other Internet-based modes of interaction (.Online Interaction.), and I further consent to the electronic transmission and storage of my Personally Identifiable Health Information. I understand that I may withdraw this consent at any time without affecting my right to future care or treatment or risking loss or withdrawal of any program benefits to which I would otherwise be entitled. My physician has provided me with the opportunity to discuss and to question the issues, risks, and policies set forth in this consent form. I fully understand the information provided.

Patient Login

Logging in is easy as 1 2 3

  • 1 Log in with your user name (email address) and password (hit Change/reset password link to create a password for your account. Do not register for an account, this will create a duplicate)
  • 2 Under Manage My Health Record complete the tabs of information about your health. Under Reports and Tools click view Recent Test Results to see a digital copy of your lab results.
  • 3 Under Contact and Communication click Check My Inbox to see messages from the office.
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