Metabolic and Bariatric Surgery Program

Transcription

1 Metabolic and Bariatric Surgery Program Patient Information Packet muschealth.org/weight-loss-surgery (843) Revised Changing What s Possible

2 To our patients considering weight loss surgery: Bariatric Surgery Program 25 Courtenay Drive Ashley River Tower MSC 290 Charleston, SC (843) phone (843) fax T. Karl Byrne, MD Professor of Surgery Medical Director Rana Pullatt, MD Associate Professor of Surgery Director of Robotic Surgery Aaron Lesher, MD Assistant Professor of Surgery and Pediatrics Nina Crowley, PhD, RD, LD Bariatric Program Coordinator Beth Fogle, MHA, RN, CBN Bariatric Nurse Coordinator Diana Axiotis, MPAS, PA-C Physician Assistant Lisa Steinbronn Patient Liaison Janine Garey New Patient Coordinator Amanda Peterson, RD, LD Clinical Dietitian Molly Jones, RD, LD Clinical Dietitian Sharlene Wedin, PhD Clinical Psychologist Thank you for your interest in the MUSC Metabolic & Bariatric Surgery Program and congratulations on your decision to pursue a lasting and effective treatment for your obesity together with our team. Before you fully commit to weight loss surgery, we strongly suggest that you contact your insurance carrier to verify that weight loss surgery is a covered benefit under your policy. Some policies exclude all types of weight loss surgery. It can be extremely disappointing to find out that you do not have coverage after going through the evaluation process. So we encourage you to find out prior to submitting your application. If your insurance carrier does not cover the procedure, please call our financial counselors at or to discuss self-pay details. Enclosed in this packet is an outline of the steps required to have surgery (keep these for your records): Steps to Weight Loss Surgery Please complete and return: Patient Information Form (page 5) Nutrition Questionnaire (page 6) Medical History Questionnaire (pages 7-10) Return by mail, , or fax: Mail: MUSC Bariatric Surgery Program 25 Courtenay Drive, Ashley River Tower MSC 290 Charleston, SC garey@musc.edu Fax: (843) When we receive your Patient Information Form, Nutrition Questionnaire, and Medical History Forms we will be in touch with you to discuss next steps. Please visit our website for more information and resources Yours sincerely, The MUSC Bariatric Surgery Team Karl Byrne, MD, Medical Director, Professor of Surgery Rana Pullatt, MD, Director of Robotic Surgery, Associate Professor of Surgery Aaron Lesher, MD, Assistant Professor of Surgery and Pediatrics

3 Step 1: Call your Insurance Company Verify that weight loss surgery is a covered benefit Ask your insurance company if the following procedures are covered at MUSC by your insurance plan: o Roux-en-Y Gastric Bypass (CPT 43644) o Sleeve Gastrectomy (CPT 43775) o Biliopancreatic Diversion with Duodenal Switch (CPT 43845) o Lap Band Removal (CPT 43774) Ask about criteria required by your insurance company for surgery approval If they ask for Medically supervised weight loss attempts - how many months (3-6 months is common) Letter of medical necessity Surgical clearances required (pulmonary or cardiac) Step 2: Document Medically Supervised Weight Loss Attempt If required by your insurance company, connect with your primary care provider (PCP) or a Registered Dietitian (RD) that may work with an MD who can help you meet this requirement Tell them you need monthly visits to discuss your weight: o One per calendar month o 30-days apart o Consecutive in order, no breaks Fax office visit notes or completed sample monthly supervised weight loss attempt forms to (843) Step 3: Complete Patient Information Forms We need your demographic, insurance, and basic medical information to get you an appointment Complete the patient info form, nutrition questionnaire medical history questionnaire, and send in to us by mail, fax, or We will get you set up with MyChart, the electronic medical record, so you can receive communication electronically Step 4: Connect with the Bariatric Surgery Team Call us at to schedule your initial consultation to meet with the surgeon, physician assistant, registered dietitian, nurse coordinator, and patient liaison We will refer you to get your psychosocial evaluation at the behavioral medicine clinic You will get labwork done at your first visit Start taking vitamins and working on your goals

4 Step 5: Initial Consultations with MD, RD, Psychologist You will be contacted to schedule an initial consultation with the bariatric surgeon, to discuss your options for weight loss surgery and have labwork Complete nutrition assessment forms prior to appointment and you will meet with a Registered Dietitian (RD) to discuss eating habits and vitamins You will need to call (843) to schedule your psychosocial evaluation with the psychologists at the Behavioral Medicine Clinic at the Institute of Psychiatry, 67 President Street, Charleston SC Keep your New Patient Appointments! If you no show or fail to cancel within 24 hours - after 3 no shows for new patient visit with the MD or psychologist, you will be dismissed from evaluation for 12 months Step 6: Preoperative Education Class, labwork, clearances Our Mandatory Pre-operative Education Class is held every 1st and 3rd Tuesday of the month from 12:30-3:00 PM in the Ashley River Tower Auditorium o You do not need to register, we take attendance Labwork is done at first visit and recommendations to start vitamins for all patients plus any for deficiency Obtain any clearances you may need such as cardiac (heart) or pulmonology (lung) discussed with surgeon o Medicaid requires cardiac and pulmonary clearances and testing of H Pylori Step 7: Insurance Approval and schedule procedure You are responsible for getting your records to us Our office will submit all this information to your insurance company for approval - it can take up to 30 days o You will be contacted when approval is received. o If you are denied, it is your responsibility to submit paperwork required for the appeal process o All deposits/co-pays must be paid prior to surgery Complete pre-operative clinic visit with PA and RD, and meet with anesthesia 1-2 weeks prior to surgery Step 8: Weight Loss Surgery! You will be admitted to the ART hospital the morning of your surgery through central registration You will be in the hospital for approximately1-2 days, and must have prior arrangements for transportation home from the hospital and an adequate care-giving plan for your first days at home Follow up for LIFE with the bariatric team annual visits after 2 years to check in, check labs, and continue to follow up with your progress

5 Bariatric Surgery Program Initial Patient Application Form Origination Date: 5/2016 Version: 1 Version Date: (5/2016) Patient Name MRN PATIENT IDENTIFICATION LABEL MUSC Bariatric Surgery Program Patient Information Form (Complete & Return) Name Birth date / / Sex Marital Status SS# Address City County State Zip Home Phone Work Phone Cell Phone Ethnicity address Occupation Employer s Name & Address Primary Care Provider (PCP) Address of PCP Referring Physician Address of Referring PCP phone Referring phone Emergency Contact Name Relationship Address City State Zip Home Phone Work Phone Cell Phone Insurance Information: (Give as much information from your card, and enclose a copy if possible) Name of Primary Insurance Name of Secondary Insurance Address Address Customer Service Phone # Customer Service Phone # Prior Authorization Phone # Prior Authorization Phone # Policy or ID # Policy or ID # Group or Plan# Group or Plan# Subscribers Name on Card Subscribers Name on Card Relationship to Patient Relationship to Patient Subscribers Employer Subscribers Employer How did you hear about us? MUSCHealth Website Internet other Facebook Newspaper Magazine Television Physician: Name: Friend: Name: Indicate the Procedure you are interested in: Gastric Bypass Sleeve Gastrectomy Other: Date you viewed online information video or Attended live Info Session: Can the patient read or write? Yes No Form completed by: Patient Other: bariatricsurgery_application_packet OTE Rev. (5/2016)

6 Personal Information: Name: MUSC Bariatric Surgery Program Nutrition Questionnaire (Please Complete & Return) Date of Birth: Height (inches): Weight (pounds): Previous Attempts at Weight Loss Efforts (Past 5 Years only): List Programs (like Weight Watchers, Metabolic Medical Center), Diets (like Atkins, South Beach), Medications (like Phentermines, Belviq), Over the Counter products (like Alli, Metabolife), physician or dietitian supervised weight loss attempts, or weight loss surgery. Name of weight loss program, diet, medication, past history of bariatric surgery Date/year you started How long on it (days, weeks, months, or years) How many pounds did you lose Daily Routine: What do you do for work? What are your typical work hours? Who else lives in the home with you? Who does the food shopping and preparation? Do you plan meals in advance? Do you shop from a list? Where do you typically eat your meals (table, couch, bed, kitchen)? Do you have any food allergies or intolerances? Are you taking vitamin and mineral supplements? (please list) Weight Loss Surgery Expectations: Which type of weight loss surgery are you interested in? How much weight do you hope to lose with surgery? In what time frame do you expect to lose this weight? Do you have any non-scale goals or things you are looking forward to with weight loss? What do you feel is your biggest challenge when it comes to changing your eating habits? Note: Plan to attend a MANDATORY pre-surgery education class which is held in the Ashley River Tower Auditorium on the 1 st and 3 rd Tuesday of EVERY month from 12:30-3pm (you don t need to register, just show up).

7 New Patient Questionnaire To be Completed by Patient Page 1 of 4 Form Origination Date: 7/07 Version: 2 Version Date: 6/10 Form completed by Patient PRIMARY CARE and REFERRING PHYSICIAN(S) Patient Name MRN PATIENT IDENTIFICATION LABEL Physician Name Address Phone CURRENT MEDICAL PROBLEM What problem brought you here? What symptoms are you having? When did your symptoms start? Has your appetite changed in the last six months? Decreased Increased Stayed the same Current Height Weight lbs Has your weight changed in the last six months? No Yes If yes, gained lbs lost lbs Has your overall energy / pep level changed? Decreased Increased Stayed the same PAST MEDICAL / SURGICAL HISTORY Have you had any difficulty with anesthesia in the past? No Yes, explain: Have you had any problems with bleeding during or after surgery in the past? No Yes, explain: Please list any medical problems (e.g., diabetes, high blood pressure, cancer) Problem Problem Females: Number of times you have been pregnant: Number of live births: Number of miscarriages: Number of abortions: Age when you started your period: Age at menopause: Hormone replacement: No Yes, number of years: Please list any previous operations or procedures Procedure or Operation Date Surgeon(s) Hospital Reviewing RN Signature Date/Time newptquestionnaire OTE Rev. 4/17

8 New Patient Questionnaire To be Completed by Patient Page 2 of 4 Form Origination Date: 7/07 Version: 2 Version Date: 6/10 FAMILY HISTORY Are there any diseases that run in your family? Disease Patient Name MRN PATIENT IDENTIFICATION LABEL Family member affected MEDICATIONS In the boxes below, please list all medications or pills that you take, whether or not prescribed by a physician. Record them just as they are on the drug bottle / box. Please include all vitamins, herbal supplements, and/or over-the-counter medications. Medicine or pill name Dose (e.g., 50 mg) How many times per day? Why do you take this? Please list any allergies. What happens if taken or Name eaten? Name Are you allergic to shellfish? No Don t Know Yes What happens if taken or eaten? Have you had an allergic reaction to contrast or dye injected in a medical test? No Don t Know Yes, what happened? Rash Short of breath Other VACCINATIONS Have you received a pneumonia vaccine within the past 5 years? No Don t Know Yes, date: Have you received a flu vaccine this flu season? No Don t Know Yes, date: Reviewing RN Signature Date/Time newptquestionnaire OTE Rev. 4/17

9 New Patient Questionnaire To be Completed by Patient Page 3 of 4 Form Origination Date: 7/07 Version: 1 Version Date: 6/10 SOCIAL HISTORY Single Married Separated / Divorced Widowed What is your current or former occupation? Patient Name MRN PATIENT IDENTIFICATION LABEL Do you currently or have you ever used tobacco? Never No / Quit Yes I would like to quit. If yes or quit, how much per day? Age you started: Age you quit: Type: Pipe Cigars Smokeless Tobacco Cigarettes, have you smoked this past year? No Yes Do you or have you used alcohol? Never No / Quit Yes If yes or quit, how much per day? Type: Beer Wine Hard Liquor Moonshine Do you or have you used recreational drugs? Never No / Quit Yes, type: Prior to this illness, did you have any problems taking care of your daily activities of living (e.g., bathing, walking)? No (Independent) Need some help / assistance Need constant help (Dependent) Do you currently have any problems taking care of your daily activities of living (e.g., bathing, walking)? No (Independent) Need some help / assistance Need constant help (Dependent) Do you have difficulty falling asleep or staying asleep at night? No Falling asleep Staying asleep Are you bothered by unpleasant sensations in your legs in the evening or in bed (such as tingling, creepy crawly feelings) that get better when you move your legs or get up and walk? No Yes If you have a bed partner, does he / she report that you kick or move your legs excessively during your sleep? No Yes I sleep alone Do you have an advance directive (living will, durable power of attorney)? No Yes, please provide copy. Do you have any religious or cultural beliefs that you would like your doctor to know about? No Yes If yes, explain: How do you learn best? Pictures Books / pamphlets Video Talking to others Computer Do you have problems with transportation? No Yes Do you have financial concerns? No Yes EMERGENCY CONTACT INFORMATION Name Phone Name Phone Reviewing RN Signature Date/Time newptquestionnaire OTE Rev. 4/17

10 New Patient Questionnaire To be Completed by Patient Page 4 of 4 Form Origination Date: 7/07 Version: 1 Version Date: 6/10 Do you currently have or have you had any of the following? CONSTITUTIONAL Fever No Yes Chills No Yes Loss of appetite No Yes Pain No Yes, location: How bad is your pain? (circle one) (no pain...worst pain ever) Type of pain (check all that apply): Burning Stabbing Tingling Dull Throbbing Constant Radiating Cramping Intermittent EYES / EARS / NOSE / THROAT Blurred or double vision No Yes Hard of hearing No Yes Nose bleeds No Yes CARDIOVASCULAR Shortness of breath No With activity At rest High blood pressure No Yes Chest pain / angina No Yes Have you been treated for this in the past 30 days? No Yes Heart murmur No Yes Irregular heart beat No Yes Ankles / feet swelling No Yes High cholesterol No Yes Congestive heart failure No Yes Have you been treated for this in the past 30 days? No Yes Heart attack or myocardial infarct (MI) No Yes Have you been treated for this in the past 6 months? No Yes PULMONARY Sleep Apnea No Yes Asthma No Yes Wheezing / trouble breathing No Yes Emphysema / COPD No Yes Have you ever been treated for this? No Yes Cough No Yes, wet / dry? Coughing blood No Yes Tuberculosis (TB) No Yes HEMATOLOIC Anemia No Yes Bleeding disease No Yes Clotting disease No Yes HIV positive No Yes Do you bruise easily? No Yes Swollen glands / lumps No Yes ENDOCRINE Diabetes No Yes Thyroid problems No Yes Reviewing Physician Signature and Pager ID Patient Name MRN PATIENT IDENTIFICATION LABEL MUSCULOSKELETAL Joint pain No Yes Back pain No Yes Arm numbness / weakness No Yes Leg numbness / weakness No Yes NEUROLOGY Stroke No Yes, date: If yes, did you have any problems afterwards? No Yes Explain: Mini stroke or TIA No Yes, date: Seizure No Yes, date: GASTROINTESTINAL Stomach pain No Yes Nausea / vomiting No Yes Vomiting blood No Yes Difficulty swallowing No Yes Heartburn No Yes Diarrhea No Yes Bloody stool or black stool No Yes Constipation No Yes Change in bowel habits No Yes Gallbladder disease No Yes Hernia No Yes, type: GENITOURINARY Painful urination No Yes Frequent urination No Yes Incontinence No Yes Blood in urine No Yes Sexually transmitted disease No Yes PSYCHOLOGICAL Depression No Yes Anxiety No Yes Mania No Yes Schizophrenia No Yes IMMUNE SYSTEM / NUTRITIONAL / MISC Cancer No Yes, date: Type(s): Has it spread to other locations? No Yes If yes, where: Chemotherapy No Yes Have you had any in the past 30 days? No Yes Radiation No Yes Have you had any in the past 90 days? No Yes Open wounds No Yes, where: OTHER Date/Time newptquestionnaire OTE Rev. 4/17