Supplemental Coding Instrument.

Transcript #:	Date:
Coder ID #:
Cost Discussions			Yes	No
Cost Discussion 1 Occurred			Y	N
Cost Discussion 2 Occurred			Y	N
Cost Discussion 3 Occurred			Y	N
Cost Discussion Initiator	Physician	Patient	Caregiver	Other
Initiator of Cost Discussion Segment 1 during the Baseline Visit	1	2	3	4
Initiator of Cost Discussion Segment 2 during the Baseline Visit	1	2	3	4
Initiator of Cost Discussion Segment 3 during the Baseline Visit	1	2	3	4
Key Communication Variables			Yes	No
Medication Cost Discussed during the Baseline Visit			Y	N
If YES, then continue coding:
Patient Indicates that Cost is a Problem during the Baseline Visit			Y	N
Provider Behavior			Yes	No
Physician Asks About a Glaucoma Medication Cost Problem			Y	N
Physician Proposes a Solution to a Potential Glaucoma-Related Cost Problem			Y	N
Physician Recommends Patient work with Pharmacist to Lower Glaucoma Medication Cost			Y	N
Physician Asks How Much Patient is Paying for Glaucoma Medications			Y	N
Physician Recommends Patient Try 3-Month Supply of Glaucoma Medications to Reduce Cost			Y	N
Patient Behavior			Yes	No
Patient Changes Glaucoma Medication Regimen Due to Cost Problem			Y	N
Patient Discusses Coping Strategies Used in the Past to Deal with Cost Problem			Y	N
Insurance and Cost Discussed			Yes	No
Patients Health Insurance or Prescription Drug Coverage is Discussed			Y	N
Coinsurance or Copayment is Discussed			Y	N
Medication Assistance Programs are Discussed			Y	N
Four Dollar Generics are Discussed			Y	N
Laser is Discussed as a Solution to a Medication Cost Problem			Y	N
Samples			Yes	No
Patient Requests Samples			Y	N
Physician Provides Samples			Y	N
Physician Discusses Being Unable to Provide Samples			Y	N
Medication			Yes	No
Term Brand or Generic Drug is Used			Y	N
Physician Initiates Discussion of Brand or Generic			Y	N
Physician Explains Difference Between Brand and Generic			Y	N
Patient Expresses Confusion of Brand versus Generic			Y	N
Physician says Generic isn’t Available			Y	N
Physician Offers to Write Prescription for Generic			Y	N
Physician Asks if Patient has a Preference for Generic or Brand			Y	N
Patient Expresses Preference for Generic			Y	N
Patient Expresses Preference for Brand			Y	N
Physician Proposes a Solution to a Potential Cost Problem			Y Only
If yes: what is discussed?
Physician Recommends Patient work with Pharmacist to Lower Medication Cost			Y Only
If yes: what is discussed?
Patient Changes Medication Regimen due to Cost Problem			Y Only
If yes: what is discussed?
Patient Discusses Coping Strategies Used in the Past to Deal with Cost Problem			Y Only
If yes: what is discussed?
Medication Assistance Programs are Discussed			Y Only
If yes: what is discussed?
Patient Expresses Confusion of Brand vs. Generic			Y Only
If yes: what is discussed?