This is a continuation of my earlier rant on Medicare/Medicaid.
…Earlier this week, it was another patient. Also with osteomyelitis (a bone infection). Doing well however. I still had this patient on antibiotics and wanted to get bloodwork to monitor for potential adverse effects of the antibiotics. Knowing that bloodwork requires an ICD-code for billing purposes (so that the lab can be paid for their work) I looked up the code for osteomyelitis and wrote it on the prescription.
Let’s back up a minute. ICD stands for International Classification of Diseases (old name) or International Statistical Classification of Diseases and Related Health Problems (new name). Every diagnosis and procedure has an ICD code. Every single one. Mind you, we learn none of this in medical school nor post-graduate training (residency/fellowship) because we are busy learning how to take care of patients, not learning how to bill and be reimbursed for our services. That wouldn’t be a bad idea, but already physicians are seen as greedy little pigs, I can only imagine what the public would think of medical schools formally teaching the business side of medicine.
It is essentially health care fraud to use the wrong ICD code eg. to bill 250.13 which codes for Diabetes mellitus with ketoacidosis type 1 uncontrolled instead of 250.82 which translates to Diabetes mellitus with other specified manifestations type 2 or unspecified type uncontrolled; especially if 250.13 results in greater reimbursement than 250.82. But if you used the wrong code leading to less reimbursement than the correct code, oh well, no one is going to audit and make sure you get what is rightly yours. Mind you, there are over 300 codes for diabetes mellitus in the newly released ICD-10. That is pure insanity. We are using ICD-9. ICD-10 for the US came out a couple of months ago and the entire health care field is expected to be compliant with these codes by 2013.
Typically, hospitals have coders who go through the medical charts and find the code for each diagnosis documented by the physician. If you own your practice, it’s pretty wise to have one of these available as well. But when you don’t yet have a clinic running with its support staff, you kinda have to look up codes on your own. Thank goodness for handheld devices such as PDAs and smartphones which now have apps for ICD codes. I can imagine the hell of times not too long ago when people would have to flip through pages of encyclopedic books looking for the code that matches the situation and praying there’s one in there.
How does coding work? Hmm. Imagine a typical day. You wake up in the morning and bump your left foot on the lower right bedpost. That’s a 123.34 If you had bumped your right foot on the lower right bedpost that would have been 123.35. If it was the left foot on the lower right bedpost, that would be 123.44. Got the hang of it? Simple right? Great!
But most patients don’t have just one diagnosis! So off you go to the bathroom and perform a procedure ie. brush your teeth. That falls under 456. Normally, you brush your teeth without any complications 456.00. Sometimes you brush your teeth without complications but use a brand name toothpaste 456.01 instead of homemade baking soda and peroxide 456.02. But today, because you didn’t hear your alarm and are late for work, you brushed hard and your gums started to bleed. That’s a complication. 456.10. At first it was just a trace of blood 456.11, but now it’s uncontrolled 456.13. You look closely and realize that you’ve totally dislodged the upper second incisor, the one that was loose anyway from your drunken fist fight two nights ago. That’s now a different code 786.67. Loose tooth as a result of trauma, type fist. Of course, if it was the lower 4th molar that was dislodged, that would be code 786.98. And so it goes. As easy as pie.
So let’s get back to my very compliant patient with the osteomyelitis who needs bloodwork, a simple CBC (complete blood count), which probably costs about $20 amongst others for monitoring of possible adverse effects of her antibiotic. Since she doesn’t actually have an adverse effect to the antibiotic and the reason for the antibiotic is the osteomyelitis that’s what I write for the code. The patient calls me herself because she is one of those who has her faculties intact, her priorities straight, and is interested in her own health. She tells me that she went for her bloodwork but the lab told her that her insurance wouldn’t cover the CBC. Apparently they would cover the CRP (C reactive protein) a far more expensive test (~$50) which tells me how active the infection is.
I was so confused but this is not the patient’s burden. I told her I would take care of it. I called her lab and they told me that Medicare didn’t accept the code I listed. I was flabbergasted. I actually asked, “so what code does Medicare want me to use to check a CBC in a patient with an active infection who is on antibiotic therapy?”. Of course the lab technician didn’t know, for heaven’s sake he’s just a lab technician! So I was bounced around, first to another lab technician, then to the supervisor, then to the “gals in medical records” who navigated the big bad world of ICD-9 codes with me and diagnosed my problem. I was missing the correct 5th digit on the code that I had written. Lord help us all.
And least anyone begins to think that my beef is only with the government’s Medicaid and Medicare and with the ongoing health care reform discussion, I have one more story. Again a patient with osteomyelitis. I know, there are a lot of them aren’t there! He has private health insurance. Do you know his insurance refused to pay for an MRI, the diagnostic imaging test of choice? Instead we were led down the path of having the patient go to the operating room, go under anesthesia, have a 3 day hospital stay for a biopsy to prove to them that he had osteomyelitis before they would cover his treatment. Incredulous. Meanwhile common rhetoric says it is the doctors who are responsible for the increasing costs of healthcare. Oh, ok then. Clearly, it does not fall squarely on us.
Where are these medical offices of Dr. Medicaid, Dr. Medicare, and Dr. Private Insurance so that patients can go there instead? Obviously those of us who went to medical school and completed residency training programs do not know what we are doing.
Again, thank goodness it’s Friday and that I’m off for the weekend.
Leave a Reply