MEDICAL REFERRAL GUIDELINES Referral guidelines are ...

1 Referenced in: Patient Care Services Policies and Procedures No. 647 Page 1 of 50 Revised as of 9-4-14 MEDICAL REFERRAL GUIDELINES REFERRAL GUIDELINES are indexed by specialty and in alphabetical order. 1. Access Clinic .. 2 2. Cardiac Clinic .. 2 3. Dermatology Clinic .. 4 4. Diabetes Clinic .. 7 5. Endocrinology Clinic .. 7 6. Family Care Clinic (FCC) .. 8 7. Gastroenterology (GI) Clinic .. 10 8. Geriatric Assessment Clinic .. 12 9. Hematology/Oncology Clinic .. 13 10. Hepatology Clinic .. 21 11. HIV and Infectious Disease Clinic .. 22 12. Internal Medicine: Procedure Clinic.

2 24 13. Neurology .. 24 14. Obstetrics and Gynecology .. 25 15. Ophthalmology Clinic .. 26 16. Orthopedics Spine Clinic .. 27 17. Pediatric Sub Specialties .. 27 18. Pulmonary/Chest Clinic .. 32 19. Renal Clinic .. 33 20. Rheumatology Clinic .. 34 21. Smoking Cessation Clinic .. 36 22. Surgery: ENT Surgery Clinic .. 37 23. Surgery: General Surgery Clinic .. 38 24. Surgery: Neurosurgery Clinic .. 39 25. Surgery: Orthopaedic Surgery Clinic .. 41 26. Surgery: Plastic Surgery Clinic .. 45 Referenced in: Patient Care Services Policies and Procedures No. 647 Page 2 of 50 Revised as of 9-4-14 27.

3 Surgery: Vascular .. 45 28. Urology Clinic .. 47 29. Wound Clinic .. 49 MEDICAL REFERRAL GUIDELINES REFERRAL GUIDELINES are indexed by specialty and in alphabetical order. 1. Access Clinic Return Criteria Comments Located in Family Care Clinic 2,The Access Clinic is a MEDICAL home designed to provide coordinated primary care for adults with chronic physical or mental disabilities, including: adults with chronic disabilities, mental or physical (including but not limited to developmental delay, Down s syndrome, Autism, paraplegia, quadriplegia, schizophrenia, bipolar disorder) with complex care needs who might benefit from improved case coordination from a multi-disciplinary team specializing in care of the disabled. 1.

4 Covered by IEHP. Requires Prior-Authorization. 2. Chronically disabled due to a MEDICAL or psychiatric condition 3. On SSI or SDI 4. 18 years or older Phone: 951-486-5573 The Access Clinic does not do disability determinations. The clinic is designed for patients with well established disabilities who have complex care needs. 2. Cardiac Clinic Return Diagnosis Supporting Documents/Tests Chest Pain Referrals a. EKG b. Exercise or pharmacological stress test with results c. Previous coronary angiogram reports (if done) Referenced in: Patient Care Services Policies and Procedures No. 647 Page 3 of 50 Revised as of 9-4-14 2.

5 Cardiac Clinic Return Diagnosis Supporting Documents/Tests d. Lipid panel results e. If diabetic: HbA1c results within the last 3 months f. Full H&P Heart Failure Referrals a. Echo reports b. EKG c. Full H&P including social history drug and alcohol history d. Metabolic panel including liver and renal functions e. Lipid panel f. TSH in patients with atrial fibrillation Palpitations a. EKGs b. 24 hr Holter monitoring if diagnostic c. Event Monitoring if Holter is negative d. Thyroid function tests. e. Full H&P Abnormal EKG a. Fax the EKG to Cardiology clinic (951)486-5145 for official read and cardiologist opinion b. Cardiologist will determine the need to see patient after review of EKG and may order additional testing for triage Murmur a.

6 Echocardiogram with significant abnormality b. EKG c. Full H&P Conditions NOT treated: a. Prior heart transplants or need for heart transplants b. Referrals generated by NP/PA without being evaluated by supervising physician. c. Children (less than 18yrs old) Referenced in: Patient Care Services Policies and Procedures No. 647 Page 4 of 50 Revised as of 9-4-14 3. Dermatology Clinic Return Diagnosis Symptoms Primary Management Supporting Documents/Tests Comments ALL Conditions a. Diagnosis related to REFERRAL . b. Current patient demo-graphics. c. Current Insurance info. d. Copy of Authorization when possible.

7 E. Must be on RCRMC REFERRAL form unless patient is a member of a managed care group which will supply their own form. f. Pathology report if biopsy has been done. If submitting a paper REFERRAL , fax all referrals to the RCRMC Provider Relations Department at FAX (951)486-4035 Phone (951) 486-4025 691 Atopic Dermatitis Red, itchy scaly papules, plaques. Annular or coalescent, scattered, hands, vesicles Moisturize with: Cetaphil, Eucerin or Aveeno Eczem Care cream 2-3/day Infants/Toddlers: Desonide or Triamcinolone cream/ointment to body; HC cream/oint face bid x 3-4 wks max. Larger children/adults: Triamcinolone cream/ointment Try treatment for 6-8 wks Only if no response to treatment. Appt urgency 1-2 months. CPT Codes: Consult: 99202- 99203 - Biopsy: 11100-11101, 88305x2 Keloid Scar / Thick, sometimes Intra-lesional steroids or If no response to treatment, Appt urgency: Not urgent Referenced in: Patient Care Services Policies and Procedures No.

8 647 Page 5 of 50 Revised as of 9-4-14 3. Dermatology Clinic Return Diagnosis Symptoms Primary Management Supporting Documents/Tests Comments Hypertrophic Scar erythematous or hyperpigmented scar Silicone scar sheets an assessment for functional impairment must be completed prior to REFERRAL . If large, send to Plastics for possible excision/treatment evaluation. CPT Codes: Consult: 99203 Inflamed Seborrheic Keratosis (SK) or regular SK Hyperpigmented, waxy, scaly verrucous papules, plaques. Inflamed SKs are red/bloody with above description LN2 or biopsy if black and if cannot determine clinically whether it is a benign nevus Only if nevus and not SK.

9 SKs are cosmetic & recur even with treatment. Patient may be charged for treatment. No cosmetic treatment is available at our clinic. Appt urgency: Not urgent CPT Code: Consult: 99203 Biopsy: 11100-11101, 88305x2 Destructions: 17000-1st 17003x(2-14) 17004 (15+) Acne Red papules, pustules white/black comedones face, back chest, shoulders, scarring Oral Doxycyline + Topical Clindamycin/Benzoyl peroxide QAM + Differin or Tretinoin QHS Treat for 3-4 months minimum If no response in 3-4 months to this treatment or if significant scarring and cystic lesions, refer to Dermatology. Appt Urgency: Cystic acne- 4 wks Acne - 2/3 months CPT Codes: Consult: 99203 173. Basal cell carcinoma (BCC) Or Squamous cell carcinoma Non-healing ulcer, erythematous or scaly plaque, crusted nodule that has increased in size or is symptomatic (bleeding, etc) Please indicate size (cm), location, and duration of lesion If biopsy has been completed, attach a copy of the pathology report Send for evaluation of lesion - not total body check If not already biopsied, need to request authorization for biopsy with consult.

10 Appt urgency: BCC: 1 month SCC: 1 month CPT Codes: Consult: 99203 Biopsy: 11100-11101, 88305x2 172. Melanoma Irregularly pigmented lesion dark asymmetric, irregular color, itch, poorly definitive margins, bleeding or irritated red/inflamed or rapidly growing Excisional bx or deep shave biopsy may be done by PCP prior to Dermatology REFERRAL Please indicate size (cm), location, and duration of lesion, If biopsy has been Send for evaluation of lesion - not total body check. If not already biopsied, need to request authorization for biopsy with consult Appt urgency: Melanoma: Urgent call clinic for appt time (951) 486-5175 CPT Codes: Consult: 99203 Biopsy: 11100-11101, 88305x2 Referenced in: Patient Care Services Policies and Procedures No.