ICD 9 to ICD 10 Transition

So I missed a couple of posts from some time off so forgive me.

This past month was very busy.

At the beginning of this month, there was the much heralded transition from the ICD 9 to ICD 10.

I'll give a brief summary again here. The CPT codes are the procedure codes that the physician checks off as he sees you. Depending on the complexity and time of the case, the physician has varying degrees of office codes in addition to any treatment codes such as vaccines, blood tests, or other procedures like EKG, etc.

Each of these CPT codes needs a corresponding ICD codes. These codes can ensure that the insurance companies can verify that these CPT codes or procedures were necessary as well as just having a documented recording of what was done.

The number of ICD 9 codes were 14,315 codes. ICD 10 will be bringing that number to more than 69,000 distinct codes.

Now why would they do this? I can list several reasons.

1. Not specific enough.

Some of the codes get very very specific. Down to the exact location. In the old ICD 9 codes some of the pain in XYZ place codes were very generic.

2. Reducing redundancy.

For example, vaccines had a CPT code and a corresponding ICD 9 code. Now they just have one vaccine code along with those CPT codes removing those ICD 9 codes.

However, there have been some transition troubles. With our EHR some of the codes we cant find on the system and our medical management software has some of them or doesn't have some of the codes. Some of the lab companies have had problems as well. We have a phlebotomist that can't find some of the ICD 10 codes that correspond with the ICD 9 codes. However, these are transition issues that I believe will resolve themselves over time as people adjust.

Rheumatology Shadowing

So this past week, I shadowed a great rheumatologist, Dr. Gradzka everyday.

Rheumatology is the study of of rehumatism(autoimmune diseases), arthritis, and other disorders of the joints, muscles, and ligaments.

It was really great to see other specialities of internal medicine. Especially with the advancement of biologics, the medicines available to treat some of the diseases has advanced. But for some of the patients there is frankly nothing that can be done except with the treatment of steroids. However, one has to be very careful of relying on steroids as they can have serious complications(see the Dr.Google case.)

It was funny, Dr. Gradzka mentioned that gold injections were once the go-to treatment. It goes to show how far medicine and treatments have advanced.

A Doctor's Touch

A video that I saw a while ago after reading Verghase's book(An incredible read)

A simple concept but a powerful, touching one nonetheless.

New Saliva Test for Alzheimers

As testing becomes more and more sophisticated and easier (see Theranos for simpler blood tests), one wonders what role the analytical aspects of a doctor will play, if anything at all.  With technology getting better and better and more widespead -- even sold by CVS for example), one wonders how doctor of the future must deal with such technologies.

I believe, however, that even with such tests, the training that doctors get and should continue to get should be an integral part of not only their training but also how they will practice medicine.  Costs will be a consideration even if a test is good as well ease of use and false negatives that will give such tests credibility.

Occipital Stroke

Pt comes in complaining of vertigo and dizziness. The Pt had fallen because of the dizziness but he did not have any balance problems. He complained of low energy, very tense, and could not relax because of these symptoms. He had earlier stopped all of his medications because he believed that they were causing his his vertigo.

Upon examination, the Dr. confirmed the symptoms and checked that he had no vision problems, no vomiting, and no chills. Dr. conducted a neurology exam and it was non-specific. Doctor ordered an MRI. The results revealed that the pt had an occipital stroke.

Pt is retaking his medications under doctor's orders. He was subsequently admitted to the hospital for further evaluation and management.

Close call

Pt called the office complaining of nose bleed and post nasal dripping.

Pt insisted that he did not have any other associated problems. Dr. advised him on the phone that he should go to the ER given that he underwent recent heart surgery and stress related issues.

Pt checked into ER for nose bleed and bloody sputum(a mixture of saliva and mucus coughed up from the respiratory tract.)

Chest x-ray in ER revealed some infiltration suggestive of pulmonary tuberculosis which was confirmed by sputum stain.

The ER had to immediately isolate the Pt. Pt is now taking multiple anti-tb medications under supervision. (They need to be supervised because if the pt misses a dose, it can be detrimental to cause multi-resistant TB.)

We still have to be vigilant of infectious diseases like TB.

It certainly was a close call as we could have also been infected.

Tech Docs...

So, even docs are not being lured by the tech siren calls....guess it's true that people went into medicine for money after all...

But young docs thinking about making millions in health tech may want to keep in mind that out of 19 named employees in the hot health startup, Rock Health, only one has an MD degree...not much of an opportunity for MDs there...

Although I can understand why the lure of tech for a group of highly educated people who are likely forced into mind-numbing routines might happen.  I work in a doctors office as an office manager and I can truly say that if policy makers don't make it a priority to keep docs in the profession, they will soon find themselves on the operating table without anyone to attend to them.

Dr. Google

Young white female presented with a history of chronic eczema or atopic dermatitis. She had this condition over several years all over her body. The chronic skin condition not only affected her physical wellbeing but negatively affected her mental wellbeing as it was very visible across her face and limbs. As a result, she had not maintained a full time job for two years.

She was using a topical steroid cream, cortisone for about one and a half years, as recommended by her doctor. After some time of steroid use, the patient was disappointed with the progress of the her skin condition, And in fact, when the patient googled the fact that steroid creams were actually bad for the skin, she was even more alarmed. So, the patient decided to suddenly stop using the cream without consulting Doc.

For the next two months, the patient had difficulties controlling her temperature when it was either cold or hot, persistent dizziness, nausea, loss of appetite, and her entire skin was swelling and oozing. She did not, however, visit the doctor because her parents told her that her reactions were the result of her own mental and psychological problems, not because of any other issues.

Finally, the patient decided to go see the doctor and explained everything, including how she found out that steroid creams were not good for her and why she stopped it suddenly and the additional conditions after she stopped using the steroid creams.

 The doctor explained that when you administer exogenous (originating from outside the patient) corticosteroids, it disturbs the negative feedback loop. The body stops producing its own corticosteroids, because the it is constantly receiving it from outside sources. So, when the patient stopped using the steroids, it has severe adverse effects on the body and can push the body into an adrenal crisis. The Doctor mentioned that in some cases the death rates for adrenal crisis like the one that the patient suffered from by stopping the steroid cream is extremely high, as much as 50%.

Why???????

An oncologist in Detroit was purposely misdiagnosing patients with multiple myeloma. Then gave chemotherapy treatments to over 500 people. In some cases, repeatedly giving them chemotherapy treatments until they were nearly dead.

Seriously, even if it was for the money just why?

The Price is Right!!

A 54 year old white male came in for a check up post motor vehicle accident (MVA) to claim for insurance or something. Anyway, Doctor asked when did the patient have his last regular check up. The patient apparently had never seen a doctor so he had a whole battery of blood tests and physical.

After his follow up, the blood tests showed some interesting results. His liver enzyme was a little elevated. His liver profile showed that he had hepatitis c. Upon a follow up appointment, the ultrasound showed that he had hepatoma and showed some significant symptoms of liver cancer(jaundice, yellow skin, etc.)

If it was back in 2000s, there would be limited treatment options, and for many a death sentence. However, starting this decade Gilead Sciences developed a drug called ledipasvir/sofosbuvir--its trade name being Harvoni. It's an absolutely revolutionary treatment and can successfully treat hepatitis c! Obviously, if you have a miracle drug that can essentially cure a life threatening disease, it will not come cheap. The total cost of a three month treatment(it is taken orally and the length of the treatment depends on the severity of the disease.) is $100,000. But if its worth your life, even at $100k, the price is right...

Treat the Patient, Not the Disease

A teenager presented with years of bed wetting (enuresis) problems, nearly every night.  As a result, he was socially isolated and had no experience of sleepovers, etc. because of his condition.

He is a very athletic, active, and academically strong teenager boy, an outstanding kid actually. Upon further examination and questioning, it appeared the boy had anxiety issues because of his mother. His mother would go to work every morning at 4 am. As a result, his father took care of him during the day. The father was apparently very strict with him.  Mother would come back home very late so as an only child he was mainly with the father and raised in a very strict environment.

One obvious solution was imipramine which is the common treatment for bedwetting as well as depression.  But the Doctor decided to forgo that usual treatment because she was concerned about side-effects, and frankly, he was not depressed.  Bed-wetting was a subconscious issue.

Instead, the Doctor asked that the patient write a monthly schedule of when he wets or doesn't wet on that night. If he doesn't wet the night, Doctor told the mother to reward him at the end of each week. Within 6 months, the patient did not have any more bed wetting problems and without the use of drugs.

I thought about this and realized that the patient had basically cured himself by visualizing on his chart his progress.  The things that caused his issues, an absent mother, a strict father, could not be changed, but the patient could be.

Too often in today’s medical environment, few doctors would take the time to understand the patient, a more difficult and more time consuming process than understanding the disease, especially since drug companies make it easier for doctors to just medicate. But that method only serves as a temporary solution not a permanent one. The Doctor went beyond that and systematically solved what was affecting the patient, psychosomatically by treating the patient rather than treating the disease.

Remember that Magic School Bus episode?

Back when I was a kid, I would watch a show called the Magic School Bus. It was about an eccentric school teacher named Ms. Frizzle who would lead her third grade class on this magical school bus that could take them anywhere.

Arnold turns orange in one episode and the whole class goes on an adventure trying to solve why he is orange. I actually had a similar case with the Doctor.

A middle aged man came in complaining of his skin tone. When I first saw him I thought that he was experiencing jaundice and other liver problems. It was that pronounced.


Of course, his skin tone was not as dramatically orange as Arnold was in the picture above.  After a long diagnosis with the patient, he just simply ate and took a lot of other stuff that made him become orange.  On a daily basis, he ate as much as two bags of carrots, drank at least a gallon of orange juice, and at least half a bag of clementine oranges.  He had originally been scared that it might be a liver issue or even cancer, and this "orange" condition even affected him personally, including his relationships and his job.

The remedy was for him to just simply stop.  In a few weeks, when he came back for a followup, he was fine.  And his color returned to normal.

Don't Lie -- Especially not to your doctor

A patient came in for a routine gynecological exam. The test results came back and showed that the patient had early cervical cancer. The Doctor informed the patient of the difficult situation.  The patient then confessed that she already had a cervical cancer diagnosis. But she had come to the Doc to confirm the diagnosis.

This situation frustrated the Doc.What if the test results had come as a false negative? Who would the patient believe?  Doc strongly believes that this is not a game of who is right or wrong. If the patient does not tell the truth, how can the doctor help the patient to best of his or her ability?  On the other hand, the patient may not have been attempting to play any games, but is understandably just worried as to whether or not the diagnosis is true.  It's more of a confirmatory test, not whether she has it or not.

Regardless, don't attempt to lie and always tell the Doc everything.  Like lawyers, Docs have a inviolate patient/doctor confidentiality and is prohibited from revealing any information about a patient to anyone.

The Troubles of Billing in a Medical Office Part II

So, as I outlined in Part I, you sent out your claim to the dozens of insurers your patients are part of.  Here is only 10 ways out of a million your claim can be denied.  The reasons below are so bad, you are tempted to do this:

Pay Up or We'll Shoot Max!!

1. You put in the wrong member ID.  Generally, the member IDs are no less than 10 digits mixed together with letters, and sometimes with special characters -- which the computer databases often do not recognize.  Years ago, there was an insurance company called _____ which had -- I kid you not -- member ids that would include % or #.  Many staff members who did billing likely ended up cross-eyed or committed suicide.  I decided to shoot a dog...Imagine if you had to type something like that over and over again every day.  That insurer should have been sued for everything under the sun. It was sued numerous times and still exists with different entities and different names and continues to make a bundle because it never pays any claims.  How can it when the member ID numbers are wrong?  Get it right and they will pay.

2. Wrong codes.  There are 68,000 ICD-10-CM codes and 87,000 ICD-10-PCS codes  and nearly 8,800 CPT codes that must be connected to the ICD-10 codes.  Oh, the ICD-10 codes are new ones being implemented this year and replacing the ICD-9 codes that had been used for over a decade.  You put in the wrong code or combination of codes and you get denied.

3. Wrong patient info. You put in wrong patient info, say an outdated address that only the insurer would know, but they will not tell you the new address because you have to get that from the patient.  Patient confidentiality man!  They can't violate that even it means they don't pay, and especially if it means they don't pay.

4. Prior authorization.  Dr. works like crazy to treat a patient and spends hours to get to the root of the problem because he walked into your office all pale and sick.  And being a doctor who can't by law deny care or you get sued, Dr. does it.  Then he claims for payment and the insurer says he didn't prior authorization.  Nothing you did is worth any value to the insurer. Sure the patient feels great, but too bad if you, the doctor, feels bad.

5. Termination of coverage. Even worse is when you treat a patient and then when you call to claim, he didn't have coverage.  the insurance card he showed had expired.  Too bad.  You get denied.

6.  Excluded or non-covered services.  You as the doctor did all you could, including an extended diagnosis, etc., but you come to find out that the services you provided were excluded or non-covered. You get denied.

7. Request for Medical Records.  You did everything you could and the insurer is valid, etc. Then, the hammer drops because some health insurance plans may require medical records when the claim requires further documentation in order to adjudicate the claim. The medical record includes but not limited to the following:  Patient medical history,

Patient physical reports, Physician consultation reports, Patient discharge summaries, 

Radiology reports, Operative reports.  That would be hours of your staff time, postage, copying, etc. only to be denied later after you've submitted it.

8.  Coordination of Benefits.  Another sneaky way is Coordination of benefit denials  which could include:  Other insurance is primary, Missing EOB, Member has not updated insurer with other insurance information. Coordination of benefits is a term used when a patient has two or more health insurance plans. Certain rules apply to determine which health insurance plan pays primary, secondary or tertiary. There are several guidelines to determine in what order the medical office must bill each health insurance plan and those guidelines are designed to keep taking you around in circles....

9. Bill liability carrier.  If the claim has been coded as an auto or work-related accident, some carriers will refuse to pay until the auto or worker’s compensation carrier has been billed. For accident related services, the following third party liability insurance should always be filed as primary, not the insurance company:  Motor Vehicle or Auto Insurance including no fault, policy or Med Pay, Worker's Compensation Insurance, Home Owner's Insurance, Malpractice Insurance, Business Liability Insurance.

10.  Timely filing:  Be aware of timely filing deadlines for each insurance carrier. You snooze you lose. Each carrier's deadline, however, are usually different! So you are on different schedules for each of the companies. 

The Latest Healthcare Epidemic: Binge-Watching Netflix

60-ish Asian woman complained of a chronic headache on her frontal side of her head and her eyes. The patient tried to bear through the pain for two weeks until she decided that it was unbearable.

She went to urgent care. The physicians did a complete blood work and CT. All of the results were negative.

Two days before an overseas trip, she went to follow up with Doc. During the examination, the patient stated that she had a check up with her ophthalmologist 6 months prior. She denied having any nausea, weakness, or vomiting.

Doc then inquired about her daily habits. The most pronouned activity that piqued Doc's interests was her Netflix watching.  She said that she used her ipad for about 2-3 hours every night before she goes to bed. As a result, Doc decided to check the patient's eyes.

She had completely mature cataracts. Doc could not even see the retinas.

But how could a patient develop completely mature cataracts in six months after an eye exam? Most likelyi:

1) It had gotten worse since her check up with the ophthalmologist.

2) Her Netflix habits aggravated her symptoms watching ipad and were straining her eyes to the point of cataracts.

However, it is important to note that cataracts are not caused by straining of the eyes. Cataracts develop mainly from sun exposure and the normal process of aging.

The baseline of the original symptoms--the chronic headache--were caused by binge-watching Netflix.

I too need to use the ipad less in bed at night. But Netflix just added a couple of my favorite tv shows...

This is your brain, this is your brain on drugs....

If you need a reason not to do drugs, read this.  And I'm not even talking about the ones that gets you high.

Patient was an elderly Hispanic woman who came in for a neurological visit. (Its amazing what internists cover...)  She came in with very severe muscle weakness in her legs and on the right side of her ribs. She did have diabetes but was taking medications for it. She had visited another doctor, a Neurologist, and another physician. Those two doctors stated that the patient may have Parkinson's disease which worried Doc.

Doc wondered how advanced the disease must be since a neurologist had already diagnosed it.

However, during the examination, Doc determined that she had hypoglycemia. She reviewed her medications and noticed that patient took both amaryl and glimepiride. Those drugs are notoriously known for causing hypoglycemia. Doc decided that she should try stop taking glimepiride and see what happens. Over time, she gradually got much better and had more and more energy. Eventually, Doc decided that all of her diabetes medications were to be stopped since her diabetes was under control.

Doc stated that some physicians often try to look for the next test and even sometimes are looking for the next pricey work up. But in our over-medicated society, drug side effects can easily be missed or even overlooked.  Sometimes the simplest things are just under your nose and no amount of tests or workups can substitute for just logical, rationale thinking.

Alert to Artists: Painting is Hazardous to Your Health

A retired man came in for severe, persistent lower back pain. He had finished painting his basement and his wife asked him to paint the second floor.
Unfortunately, he fell off the ladder. He had slipped and fallen on his back. He got acupuncture treatment for one month including x-rays which showed L2 compression fracture. He has more pain when sitting down (which compresses the vertebrae compared to when he stands)

Thus, the patient had severe pain any time he was sitting down. Other specialists tried to give him steroid shots which were not successful.

After the failed shots, Doc referred the patient to a spine surgeon. The patient underwent vertebroplasty which is an procedure for stabilizing compression fractures in the spine. Bone cement is injected and the cement hardens, stabilizing and supporting the spine.

This kind of surgery will usually relieve the pain compared to all of these conservative treatments.

It was initially said to see that the couple could not fulfill their lifelong dream of traveling around the world together.  Fortunately, when I saw them the second time around when they came back to the office, the patient was almost pain free. And their trip around the world was just delayed by just a year.

I might think about being an orthopedic surgeon because the surgery literally changed the retiree's life around.

Babysitting

Middle aged woman came in today complaining of hand pain for sixteen years. The pain was on and off and began after the birth of her first child.

Every time she uses her hands, she gets numbness in her 2nd, 3rd, and 4th fingers of her hand. She denies any strength problems. In her daily life, she lifts alot. She baby sits 6 months to 15 month old babies.

Upon physical examination, she had clear tinnel signs. (The Dr. uses the hammer and taps the patients flexor side of the wrist.) The patient's wrist would clearly withdraw every time she was tapped. (Doc demonstrated this when she tapped me and nothing happened)

Patient did not have any signs of thenar atrophy in her hands.  Which is good because that means the medial nerve was not significantly damaged. She did not have positive phalen sign.

The patient was told to rest the wrists and keep the wrists at 15 degree mild dorsi flexion while she is sleeping as well as avoiding overuse of the wrists.

Unfortunately, if her job is to babysit fairly heavy children who must be lifted because they cannot walk, patient may eventually suffer more.....

The Tilt Test

A longtime patient of Doc, a middle-aged Asian woman, came in for a checkup.She was completely fine. She did however have certain episodes from a decade ago.

She would have prodromal symptoms like sweating in the palms and feet and hazy, blurry vision. Then all of a sudden she would pass out! Whether she was sitting or standing, it would not matter, she would pass out if she incurred these particular symptoms. Non-specific beta blocker had to be prescribed for the patient. Since she was prescribed the medication she did not have another episode for almost20 years and had been Doc’s patient since.

The patient went to nationally known emergency rooms three separate times. Each time, the ER did a CT scan, blood work, and the all of the results came back negative for any abnormalities.

 Doc happened to be on call for one of those ER visits.  They stated it was not a seizure and there was no indication of cancer or other serious diseases. However, when Doc answered the phone, she had a strong inclination that it might be neurocardiogenic syncope.

To confirm this, the patient was immediately scheduled for a tilt test. This is a controversial test. Patient would be given isoproterenol in an effort to induce symptoms of passing out to confirm the diagnosis. (The tilt is gradually increased upwards, which would then induce higher blood pressure, but because of the isoproterenol, the patient’s blood pressure would decrease thereby creating fainting episodes). Isoproterenol is supposed to increase the blood pressure and heart rate but her body was reacting in a completely opposite manner.

In all their years, the cardiologists doing the tests had never seen someone react so quickly to isoproterenol.  Her beta fibers were reacting oppositely.

Cardiogenic syncope is thought to have 3 separate causes:  1) the brain; 2) the patinet's own psychology or mental state; and 3) the heart.

For the patient, it was obviosuly her heart that was the issue.

Liver

A patient came in with known history of liver cancer. He came in with itchy skin and it was clear the patient of suffering from jaundice. He had yellow eyes and yellowish dark skin. Even though he has a dark tanned complex it was still obvious that he had yellow skin. Yellow eye (sclera)

He was also having a fever, loss of appetite, and indigestion plus abdominal bloating and mild chills. Doc thought that he might have growing existing hepatoma blocking the bile duct causing obstructive jaundice associated with fever consistent with acute bile duct infection(acute colongititis) Or bile duct stone. He was sent to ER and admitted to regular medical care. They confirmed acute colongitis from growing hepatoma. He underwent immediate ERCP(define) endoscopic Sphrinctroctomy.

The surgery relieved the obstruction but he suffered arterial injury complications. He had to take 4 units of transfusion.

I just found it really interesting how the symptoms were so pronounced in his skin color and general condition.  One look and it was clear the patient was seriously ill.