Docnotes

Comments and RSS

OK .. so I turned comments back on here .. so we'll see how bad the commentspam is this time .. and in the context of Enoch's post on the topic ..  we may turn off comments over at medlogs .. but I'd sure like to have something in the RSS or ATOM feed to help resolve this ..

Is it Cancer?

Today I called someone who may have cancer.  This is always a tough call, since at this stage, there are no clear answers yet.  We often know more about what things are NOT before we know what they are.

• "There is something on the ultrasound that looks suspicious"
• "What is it?"
• "I'm not sure"
• "Could it be ... ?"
• "Cancer?   Yes .. it could .. but it's not likely to be ..."
• "What should we do?"
• "We'll need to do some additional testing ... such as .. "

This is usually how it goes.  I always say the "C word" early in the conversation.  This gives us both permission to say it .. since it's always lurking in the background if we don't bring it out in the open.   Next, I need to reassure the patient that the likelihood of cancer is small.  This is often calming, but of course the worry persists.  Why do I say that the likelihood of cancer is small?  Because it usually is.  Much more often, abnormal findings are just abnormal findings. 

Of course we need to do our very best to follow through carefully, do appropriate and thorough physical evaluations, etc ... and not ignore abnormal findings.  Yet the fear of the "really bad" outcome can be enormous and unnecessary, since a great deal of the time, the final result is reassuring.

Medlogs: RSS and comments

The medical weblogs aggregator is getting more use these days ... we're getting closer to an RSS feeed (of rss feeds) so if you want to use your aggregator to read the medical weblogs aggregator .. you can. 

The other experimental addition is the addition of comments.  Blogborygmi posted the other day on the expanding use of medlogs.com, and lamented:

One concern with medlogs.com is that it'll stifle reader comments -- ya can't see 'em from their site, and you're less likely to visit a blog if you've just read the latest post on an aggregator. (Something's gotta explain the dearth of opinions lately). And it seems kind of arbitrary which blogs are indexed in toto, and which get the blurb treatment.

a)   Well .. I agree that comments can be useful and interesting, but they're not part of the RSS feed that weblogs publish .. so there would be no way for us to show the comments or add a method of building the dialogue.  The next-best thing would be to host the comments ourselves and build a threaded discussion.  Dave wants to do this .. so then medlogs would become the slashdot of medical geeks (we'll call it DaveDot).  Short of DaveDot .. we've turned on Haloscan comments.  IN the title bar of every post, you can post a comment about that post in medlogs.  This may provide a method of maintaining comments - without the need for every weblog to host comments.  As you can see .. I've disabled comments on Docnotes due to too much commentspam.    We'll see how this works.  Please let us know what you think.

b)  Regarding the arbitrary nature of the how much of the weblog appears in Medlogs .. it's all about the RSS.  Some RSS or Atom feeds provide all of the post - so we provide that to you on medlogs.  Other feeds have only an excerpt .. so that's what you get.  So it's not arbitrary at all ...  and in fact, I'm not sure which one I like better.  We would certainly be able to cut off part of the feeds (so all feeds show only an excerpt) and sometimes I think that this would be better (especially for the graphics-intensive feeds) .. but if we had only an excerpt, we'd have to be clicking on the URL for the post every time .. which defeats the "get it all here" concept of the aggregator.

 

Goin to the ER

From "A Chance to Cut is a Chance to Cure"  This note about sending patients to the ER.

In primary care .. it's not so clear as in general surgery.

Yesterday I met a patient at the office (yep -- Saturday afternoon) who called with "doc I feel just rotten." It would not have been appropraite to send him to the ER ... and some may have had him take some tylenol and come to the office Monday AM. ..

when I saw him, I was glad that I did what I did.

Temperature was 103. Exam revealed cellulitis of the right leg ("well, my leg did hurt some") and a blood sugar of 156.

(no known medical problems, by-the-way)

So now you know the diagnosis.

While I doubt anyone would argue that this would have been an abuse of an ER .. I think that most would agree that cellulitis and a new diagnosis of type 2 diabetes is more appropriately managed in the primary physician's office -- where follow-up can be arranged (he's doing much better today) and continuity is maintained.

How to bill?

99215

99050 (rarely paid .. but we'll ask the insurer for it anyway)

90788

J0696

J0696

682.7

250.90

Billing woes ...

A few weeks ago, I pointed to an article on billing for mental health services in primary care.   I was surprised that the author suggests that primary care physicians can use 908XX  CPT codes.  I've never done this, and asked our medical director what he thought.  His initial response:

.... many/most of our health plans will likely not reimburse us for these services because of their requirements that mental health diagnoses be treated within their mental health network. If Medicare were to pay, they would pay at the reduced mental health rates. So, it doesn't sound like a good idea any way you look at it.

My morning project confirmed his thoughts .. and then some.  It gave me a little glimpse of what our billing staff attempts to deal with on a daily basis ... and is a great example of why our health system is simply broken.

Better rewind to March, 2003 to catch you up.

• I see a patient with bipolar disorder in the office for a follow-up visit.  I had initially referred him to a psychiatrist for help in confirmation of the diagnosis, and support in medication selection.  After about 8 months, the patient was doing very well and asked if he could follow-up with me for this problem and monitor his medication levels, etc.  Both the psychiatrist and I felt that this would be just fine.
• So our first follow-up visit went well, and I coded the visit with a 99213 and an ICD-9 code consistent with the diagnosis.  Bill goes out for $74
• The bill went to the primary insurance company, but since an ICD-9 code that was consistent with a mental health diagnosis was used, the charge was denied.  The patient's insurance coverage dictated that all mental health benefits be managed by another company rather than the primary medical insurer.  So after our billing department got the denial, the bill was re-sent to the other company.
• Since the other company doesn't have me on their list of  "in-network" psychiatrists, the charge is applied to the patient's deductible.  (not yet met) So nothing is paid.
• Now it's 6 months later ... 11/03
• Our billing office sends patient a bill.  12/03
• Our billing office sends patient a bill.  1/04
• Our billing office sends patient a bill.   2/04
• Patient is mad.  Has called us a few times .... we call insurance company ... patient told by our billing office that this is not paid by insurance since deductible for mental health services wasn't met .. so they need to pay the balance of $59 ($15 already paid .. patient's co-pay).
• Patient calls insurance company - who tells patient that physician made billing error, submitted wrong code.  If we re-submit with "a medical code" then bill will be paid.
•  ... more of the same ... now it's 6/22/04 .. my day off .. billing specialist asks me if I want to write off the $59 since the patient is on the phone and still very angry about bills from us that keep coming.
• I have 10 minutes at home to call insurance company.  I don't think I made any error.  Coded accurately for a diagnosis that is appropriate to be managed in primary care.  It's not like I coded for a psychotherapy CPT (I'd never DREAM of making that mistake .. despite the article in PCC!)
  •    Call provider services number.  Navigate through voicemail.  Enter my tax ID number, patient's SSN, patient's date of birth.
  • Wait on hold 15 minutes
  • Talk with human who tells me I have to call another number.
  • Repeat process above - waiting on hold  only 10 minutes this time
  • Human answers ... reviews bills with me and suggests that we re-submit bill with a "medical code" such as insomnia or fatigue.  She explains that the psychiatric ICD-9's go automatically to the mental health services company.
    • So any time I code for depression or anxiety you won't pay?
    • No .. we'll pay for it just fine
    • But this got denied
    • Yes .. because the mental health services company didn't deny it
    • It sure feels like they denied it.
    • Well, they didn't send it back to us
    • Why not?
    • Because they applied it to deductible since you're out of network
    • No I'm not .. I'm in your network
    • But your not in their network of psychiatrists.
    • Of course not
    • So If they had denied the claim AND sent it back to you .. you would pay it?
    • yep
    • OK .. how can we make them send it back to you
    • why don't you try re-submitting it.
  • Re-submission was not something I wanted to embrace and I politely explained that I was not hanging up until we had all figured out a solution right now .. rather than rolling the dice.  After about 15 minutes on hold .. and some more conversation, we got the representative from the other company on the phone.  She couldn't help us, and felt that everything had been done properly and that the patient was responsible for the balance.  I suggested that this was simply crazy, as it would mean that primary care physicians would never be paid for mental health ICD-9 codes.
  • At this point, she volunteered the same suggestion the other representative had shared: I should be using a "medical" code describing the symptoms rather than a more accurate (and legitimate) mental health code.
  • I suggested that this would be fraud and she shut up about that and agreed that no one is suggesting that I submit a fraudulent code.
  • (Medical) health insurance lady brings up a secret (to me) clause that says that the patient gets six mental health visits covered under the medical insurance .. before mental health coverage should be invoked ... so mental health company should have denied the charge based on the fact that there were fewer than six mental health claims.  The denial from mental health company would then cause the bill to go back to medical company .. where it would be paid.
  • (Mental Health) insurance lady thinks about this a minute and then says it won't work.
  • So I ask for supervisor
  • She puts us on hold (So I'm on hold with medical insurance lady .. and it becomes clear that she is motivated to get this claim back into her company so she can just pay it).
    • Supervisor is in a meeting, please hold a bit longer.
    • Supervisor still in a meeting, but I asked her and she says go ahead ... so we will deny the claim based on six visit rule and you should have it back to medical insurance company within a few weeks.
  • I suggest that "should" and "a few weeks" are not reassuring to me and that we really ought to be able to get it back right now ..
    •  how about you two exchange fax numbers and we take care of this now?
  • (Mental Health) insurance lady:
    • I'll put this in the system and request that it be done soon
    • (me:) ... uuh .. no .. I'd like you actually DO it instead of plopping it in someone else's lap to take care of later.
    • OK

So it took a bit more than 90 minutes of my time this morning to get paid on a $59 balance from 15 months ago.  Our billing specialist spends her days like this.  We have thousands and thousands of dollars of write-offs every months ... for things that we just don't have the energy to follow-up on.  The system is simply broken.  Every company comes up with their own methods of trying to deal tactically with the small problems they see  .. and of course, we respond with our own tactics .. such as hiring billing specialists to argue with theirs.

But what in the world does this have to do with health-care?  Oy ... not much.  Will I hesitate before coding for mental health ICD-9 codes?  yep.   Primary care of the future:

• I'm feeling really down, Doctor
• You've got a sore throat today, too, don't you Mrs Jones? (wink wink)  462.0 
• Uhhh .. nope .. I'm depressed.  (311.0)
• Do you have joint pain? (719.0)
• nah .. I'm just really sad .. no physical problems today.

 

Geek Notes

Dave installed FCKeditor into our MovableType installation.  It's better than HTMLArea, but it will take a bit of getting used to.  HTMLArea had been acting funky ever since we installed the new version of MT.  I'm surprised that MT doesn't come with a WYSIWYG editor.  There are so many available ... 

Let's see how it handles images.    Not bad.

Sam's baseball team (which our practice sponsors) won the "majors" division in little league this session.    See .. that's us .. Slingerlands Family Medicine .. in 1st place!

I took the picture with my Treo 600 .. and I continue to be impressed with it, though I'm on my 3rd one ... (all replaced for free by Sprint) so I can't say much for the quality control.

Still not able to get a good moblogging tool to work on it... any suggestions? 

Well .. if you do have a suggestion, you'll have to post it on your weblog and send me a trackback .. or send me an e-mail.  I've turned off comments on the site, since I now get over 200 comment spams a day.  MT 3.0 lets me screen them before they get posted, but I just don't have time to review 199 spams to approve of one "real" comment every day.  Soo ... comments are gone.

Final Geeknote:  We're playing with an rss feed of rss feeds .. it's an RSS version of medlogs.com.  Still in the early stages .. and not yet clean .. but here's a peek.

 

Imaging for back pain, PSA, etc

Another article looks at the question of whether imaging is helpful for the management of back pain.

Ever since my MRI in 1989, I've known I had an L5S1 disc herniation.  (I'm not alone, of course) The MRI didn't change my treatment - indeed, I think that in the first few years after my diagnosis .. I was less active because of it.

The pressure to do something and know what it is often is blamed on the patient, but I think physicians are guilty of such behavior just as much - if not more.  Patients learn from the physician .. and I can say with some confidence that patients and physicians can learn from each other to work toward healing without ordering unnecessary tests.

... and speaking of unnecessary tests, I ordered a PSA last week for a patient who had chosen (after lengthy discussions) not to have it done the previous two years. 

The result was not what we wanted .. and I thought instantly of the recent JAMA paper.  oy.

Next topic  ...

Lyme disease is quite prevalent in these parts.  I've seen a handful of very severe cases, and saw my first case of a true Erythema Migrans rash today.  Impressive.

Zafirlukast for yeast infections (!)

From STI: Here's the abstract. It's an interesting idea .. though I doubt the local HMO would cover it. Zafirlukast for severe recurrent vulvovaginal candidiasis: an open label pilot study D J White1, A Vanthuyne1, P M Wood3 and J G Ayres2 1 Hawthorn House, Department of Sexual Medicine, Birmingham Heartlands Hospital, Hospital, Bordesley Green East, Birmingham B9 5SS, UK 2 Department of Respiratory Medicine, Birmingham Heartlands Hospital, Bordesley Green East, Birmingham B9 5SS, UK 3 Department of Clinical Biochemistry and Immunology, Leeds General Infirmary, Great George Street, Leeds LS1 3EX, UK Correspondence to: Dr D J White Hawthorn House, Department of Sexual Medicine, Birmingham Heartlands Hospital, Hospital, Bordesley Green East, Birmingham B9 5SS, UK; David.white@heartsol.wmids.nhs.uk Background: Recurrent vulvovaginal candidiasis (VVC) has been linked to allergic disease, particularly allergic rhinitis. Objective: A pilot study to assess the possible use of the leukotriene receptor antagonist zafirlukast as a treatment for recurrent VVC. Methods: 20 women with six or more symptomatic attacks of VVC in the past year (at least four proved microbiologically). Clinical atopy determined by the International Study for Asthma and Allergies in Childhood (ISAAC) questionnaire assessed blindly. Monitoring by daily symptom diary and self taken vaginal swabs. Treatment with zafirlukast 20 mg twice daily for 24 weeks or until three microbiologically confirmed episodes of VVC. Response assessed by daily symptom diary and self taken vaginal swabs. Subjective response scales for improvement, side effects, and change in other allergic disease completed when stopping treatment. Semistructured telephone interview 1 year after stopping medication. Results: 14 patients (70%) reported a subjective response on the improvement response scale. Six (30%) showed a complete response with no further symptomatic attacks of VVC or negative swabs when symptomatic. Seven (37%) remained symptom free 18 months after entering the study—that is, 12 months after stopping therapy. 11 (58%) remained symptom free for at least 3 months after stopping therapy. This does not include one patient who remained symptom free but continued on zafirlukast because of an improvement in her asthma. There was no clear relation between response and atopic status. Six of nine atopic subjective responders reported improvements in other allergic symptoms. Side effects were minimal; one seemed clearly attributable to the drug. Conclusion: Zafirlukast offers a potential new treatment for recurrent VVC that requires confirmation in controlled studies.

Smoking is ...

I read Dave's post on when he quit smoking to a patient in the office tonight. I was trying to break through the iron wall of denial. No dice. "Doc, I'm not gonna quit .. I like smoking." How many physicians does it take to change a lightbulb? (answer)

Is This Child Dehydrated?

JAMA:Is This Child Dehydrated? Here's a pdf of the article .. just for my own personal use ;-)   .. it's an excellent review of a complex yet very common topic.