99238

No matter how down I am on the day, the week, the world, and healthcare in general - at the end of the day, when have I finished reading and coding a hospital stay for a patient, I am always happy to see these five numbers:

99238 - discharge services less than 30 minutes

Rub some dirt in it and get back in the game, folks. It's all we can do.

Soft Shell

I must be going soft.

I am very big on personal responsibility and accountability. That is why I get bristly when I come across patients who, through poor lifestyle choices and non-compliance, jump on the dole by way of taxpayer funded healthcare.

Lately though, I have started to be less angry and more full of disgruntled pity.

Should I be continually pissed off to see my tax dollars pay for people who don't care enough about his or her own health to be compliant, lose weight, stop smoking, drinking, or consuming drugs?

Or should I be filled with unbridled pity that these people won't  live out the decade? 

Where for art thou, Turtle?

Sorry for the extended absence, folks.

ICD-10 prep is kicking my ass. And I still have mandatory 'coder on call' shifts yet to arrive.

T-minus 27 days - and warning - if you have an appointment scheduled for October 1 please bring your patience and be extra nice to your provider!!

Paging Dr. Haiku

Seen in a chart today under HPI -

in today for pain
mobic not working that good
knee is still hurting

Written just as you see it above.

I decided to read it out loud in a dramatic Captain Kirk voice and got a standing ovation by the coder next to me.

A good day.

Awkward

My son, upon opening and reading a graduation card from his Gran in FRONT of his Gran, said out loud:

"Well. That got deep fast."

Yep, that's my boy. 

XXX

In the medical field, there lives a myriad of acceptable abbreviations. Everyone in the medical field understands what these mean. It's like back in the day with shorthand. If you know the language, you can read it. If you don't, you can't. Simple.

So, take the use of X. The letter X is commonly used by providers to finish a word they simply are too overwhelmed to finish off.

For example:

Fx - fracture
Tx - treatment
Rx - prescription
Sx - symptoms
Dx - diagnosis
Ddx - differential diagnosis

So pretty clear cut, right?

No.

Today, in a chart, a provider stated : Pt (another shortcut) here for CPX.

I had to pause for a moment. Although I've been in the medical field for quite some time, this one was new. So I kept reading. Then I got it. Patient here for a routine physical.

Now.....normally, a routine physical is abbreviated to CPE. Comprehensive physical exam. So I had to ask, "Turtle, isn't E easier to tap on the keyboard than X?"

There was no answer from the universe around me. Why would the provider choose a more difficult letter to finish off the completion of an already abbreviated procedure?

The use of X has gotten way out of hand! Stop it! Just....no.

Stop it or I will hunt you down and cause you APX (acute physical pain). Yeah, I made that up!

I fully expect, if this is allowed to continue, to read something like:

Px here for fx fu. Tx plan by Dr. X and rx called in. Rdx following. Sx include pain at site, ddx possible sepsis. Pls sx pt for CPX in six months.

What? Ugh.

I don't remember getting a decoder ring when I was hired.

Triple Crown

Years ago, after a short hospital stay, my father opined, "If you stay in the hospital long enough, they will kill you." Never thought much more about it until I entered medical coding and boy, was he right.

It's like the Run for the Roses.

And.....they're off!

And it's Afib early out of the gates with a strong start, followed closely by Anti Coag.

Afib and Anti Coag holding strong in the lead going into day 1.

As we round day 1, it's Afib and Anti Coag holding the lead spots, CDiff is bringing up the rear of the top three and eyeing the track ahead closely. Trochanteric FX, who had a rough start, a distant fourth, followed by History of Falls who is trying to assert its place in the lineup.

Coming into day 2, it's Afib and Anti Coag holding strong, CDiff a few strides behind in third, Trochanteric FX lagging terribly in fourth. History of Falls is history.

And we round day 2 with Afib still in the lead, Anti Coag in second, and CDiff in third. And Trochanteric FX goes down! What a stumble! And Trochanteric FX is out of the race! Devastating!

And into day 3 we go......And CDiff makes a break! Closing the gap on Afib and Anti Coag!! What a remarkable turn of events! Who would have known CDiff had the strength! CDiff overtakes Anti Coag from the inside and sets its sight on Afib as we round out day 3.

And coming into day 4 - , CDiff overtakes Afib for the lead!! Remarkable endurance! Did you see how CDiff squeezed through like that! And we have CDiff in the lead, folks, widening the gap for first over Afib and Anti Coag.

And we round out day 4 with CDiff in the lead, Afib a memory, Anti Coag an after-thought in third. Trochanteric is being led off the track. Godspeed. A fine showing.

And into day 5 it's.....LOOK AT THAT! It's MRSA! MRSA, who barely made it out of the gate, MRSA, who was discounted by all as a remote chance is now galloping full speed - MRSA, who had been rounding the days quietly as if on a summer stroll, now overtaking Anti Coag, sights set on Afib, while CDiff struggles to maintain the lead!

And now, rounding day 5 it's still CDiff in the lead. MRSA looks mighty strong.....overtaking Afib and leaving Anti Coag in the dust! Hard to believe those two started so strong. Now all eyes are on CDiff and MRSA.....what a race! Can CDiff prevail? Or will the silent sleeper MRSA finally be recognized as a contender in this race?

All eyes on CDiff and MRSA.....CDiff struggling to hold the lead, MRSA ....and MRSA from the outside! It's MRSA! Overtaking CDiff for the lead! Approaching the finish line it's MRSA! It's MRSA - winning out over very strong contenders Afib, Anti Coag, and CDiff.....

And it's MRSA, for the win.

Yep.

Big Brother on Z79.52

As a medical coder, I've been ready for the new ICD-10 code set for three years. Bring it on, I say. Because I'm sick of the training, re-training, and refreshers. I got it already. Jeebus.

During that hang time, each year, the American Medical Association begged, pleaded, sobbed, cajoled, and lobbied on behalf of providers in the country to put off this huge undertaking of getting on a coding system that the rest of the world has been using for decades.

The AMA cited cost as the overarching obstacle for providers; training, updating EMRs, extra staff to field denials, or the new code system doesn't go with my tie. 

But, that is the AMA. They want to protect providers and I am on board with that no matter how many ICD-10 refreshers I am subjected to.

I'm more dubious about the much larger picture this new code set provides to insurance carriers and just what those carriers will do with this shiny new influx of medical information. 

For example, right now, V58.69 is indicated for long-term use of medications. The medications that fall into this category can be methadone, opiates, and other painkillers. It's ambiguous. The medication could be anything 'not elsewhere classifiable'. 

Not anymore. With ICD-10, a code can be assigned that specifically states long-term use of opiates. No more hiding that monkey. 

Obesity, too. Right now, the code is either 278.00 for obesity and 278.01 for morbid obesity. It's not specified as to why a person is obese. 

Not anymore. With ICD-10, there are codes that indicate if the obesity is due to medication being taken by the patient or due to excess calories. 

For nicotine dependence, there used to be one code routinely used: 305.1. Now, there are different codes to indicate if it's cigarettes, chewing tobacco, or other. (Other being patches, gum, lozenges, or e-cigs). It's all out there now. 

Right now, carriers are assigning risk pools with the ambiguous system we have in place because that's all they have.

Not anymore.

This new coding system is going to seriously change the landscape of assigning patient risk that, in turn, drives premiums.

It's going to be interesting to see what happens because this new system has been lauded as the best thing since the birth of the HIPAA fairy.

Cake

Ahhh....the living wage. 

I can remember a year ago when this topic started to rear its head in the news. I can also remember taking to social media to throw in my support. Many of the people in my circle thought I'd finally had a fucking nervous breakdown considering how rabidly narrow my views can be on certain topics. (I am very serious about personal responsibility and accountability and have little to no sympathy at times.)

But yes, I was for the living wage. Seattle was the first to jump on board and I applauded the $15 threshold to anyone who would listen. 

But it's not because I gave a rat's ass about those working people or believed that $15 an hour should be the minimum wage because I'm nice and compassionate. I'm not.

It's because I knew, after crunching the numbers, that anything above $13.25 an hour would get a family three off Medicaid and food stamps. 

So I was pretty disinterested in anyone who was champing to raise the wage to $10 an hour. Completely ineffective, in my opinion. Double dipping the system at that point.

Ahh yes. My motives are sneaky at best. But hey, workers win by getting their precious living wage, and, as a taxpayer, I win because those workers can quit squatting on my paycheck in the form of Medicaid and food stamp budgets. 

So, in Seattle, at least, the workers got what they wanted. 

And the Seattle business owners were so incredibly pleased and righteous at proclaiming that they, YES, believe workers deserve a living wage and dagnabit, we are going to show the country it's the right thing to do!!

So imagine my surprise (not really), when perusing the news this afternoon, that I found a headline that specifically addressed Seattle's business owner's dumbfoundedness that workers are now demanding LESS hours!!

Why? Oh. So they don't lose their Medicaid and food stamps. 

Does it get any richer than that?? It's absolutely delicious.

Workers demanded a fair living wage. Cities gave it to them. And only now are these workers starting to realize...hey wait a minute! 

"You mean I have to pay taxes now? And buy my own food? Oh hell no....and pay for healthcare?"

Now Seattle business owners are scrambling to find help because people are just not showing up for work. Talk about bite the hand that feeds you.....literally.

I cannot WAIT to see what Los Angeles does - which is the next large city to phase in living wage over the next five years. 

I bet they put the brakes on that post-haste.....or lose votes. 

Or find some loophole and raise the poverty level to include......hell even me!

File 13

Reading doctor's notes and billing for his or her services for a living provides me with a unique perspective on a wide array of hot health care topics. I have a pretty accurate view of patient type, payer type, hospital outcomes, unpaid balances, and my favorite.....waste. 

And that is what galls me to no end. The wasted health care resources that could be better utilized elsewhere. 

I am not referring to hospital waste, unnecessary tests, inappropriate drug administration and things of that nature. Sure, these things exist, but with the JC all over facilities to bend over backwards to meet the standards patient care, waste will happen. "Better safe than sorry" is how most facilities and providers approach patient care nowadays.

I am referring to patient waste. 

Case in point:

Patient presents to the ED at 2 am. H&P illustrates that earlier that day, while getting in the car, patient is pretty sure a stink bug was sat upon. Patient didn't think much about it, but later started getting itchy 'down there' and was worried about having been bitten and/or stung. 

I would love to hear anyone's explanation on how this qualifies as an ED visit. A non-venomous stink bug.

Oy.

Case in point 2:

Patient presents to primary care because earlier in the day, patient stepped on a bee, removed the stinger, iced it up, but needed to be seen urgently (!) because the area on the foot was still red and sore at 4 pm.

People. Just ..... no.

So when I hear public complaints about how ridiculous ED wait times are or how difficult it is to get an appointment in primary care I have to either laugh or open a vein.  

This country has just gotten to a crazy point where no one can deal with or tolerate any amount of discomfort so off to the ED they go or to the phone to harass the front desk staff in primary care to demand a same day appointment. 

Wasted health care resources. 

There really are enough doctors to go around. There are just too many wasteful patients clogging up the resources.  

A Public Service Announcement

Most times, I try to stay out of the business of explaining to laymen the nuances of health care billing issues. Probably because it always ends up with me trying to defend stupid insurance rules, which is not a point of strength for me.

But this one really has my hair up. And the public should understand this nuance. So here you go, public:

"We're going to admit __________."

Fill in the blank with you, your wife, your husband, your mom, dad, grandma, son, daughter...etc.

Upon hearing these words from a doctor, most are overjoyed that FINALLY someone is listening and they've decided to put ________ in the hospital!

We are going to get answers! He/She is not just making it up! Ugh.

Cell phones blaze in a moment of glory.

But let's pause the video here for a moment, Bob, because there is some vital information missing:

Let's review:

"We're going to admit ________ to observation."
"We're going to admit ________ to inpatient."

See those two words at the end? Those two words mean everything when the bill gets calculated and the amount owed by the patient is tallied.

Because of the fairly recent CMS (Centers for Medicare and Medicaid Services) two midnight rule, when evaluating a patient, doctors must determine whether or not he or she thinks the patient will require less than a two day stay or at least a two day stay.

If less than two day, the patient is placed in observation. If more, the patient is placed in inpatient. (And don't get me started on Condition Code 44. That is yet another post.)

Observation means outpatient status. Yes, you or your loved one is in the hospital, but did you know that you can be considered an outpatient yet still be in the hospital? Maybe not.

Inpatient means really, truly, and most assuredly in the hospital and likely to visit many a step-down unit like cardiology, pulminology, ICU, etc.

This all matters because of how insurance will pay.

Insurance plans pay based on whether or not the service is provided under outpatient rules or inpatient rules.

While I am reluctant to provide a dissertation on every insurance carrier known to man and Obama Care, please know that those two simple words make a difference.

It's important to ask your admitting physician whether ________ is being admitted to observation or inpatient status and to also ask WHY.

Although, I am quite sure that after 1mg of Dilaudid the patient won't care, and neither will the family because the bitching has finally stopped, but anyway. ASK.

Then you attain a position of knowledge and hopefully won't have a heart attack upon receiving the bill which will then put you in the hospital under either outpatient observation or inpatient status.

This has been a Public Service Announcement. Thank you for your time.

My dad was right:

Stupid should hurt.

Now I know there is a smart-ass gene

Driving home from errands today with Chris in the car. He had valiantly volunteered to accompany me to to the store. Of course, this trip was somehow coupled with a quick (extorted) detour to Game Stop, but still.

I will take the company of my teenage son even if I have to pay for it.

Cruising up the road to the house, I started griping about the road and how the dump trucks going back and forth for construction have completely ruined it. There were potholes everywhere.

What follows is as true a transcription as I can conjure after a much needed beer:

Me: <griping about the potholes>

Chris: They don't bother me really.

Me: Well, they don't bother me either. I mean like, as a person. It's the car I'm worried about!

Chris: What's wrong with the car?

Me: Well, nothing yet. But the alignment is going to hell.

Chris: What's an alignment?

Me: <thinking> Okay, well take a bike, for instance....

Chris: You mean, like steal? Because that is wrong. Are you suggesting I steal a bike for your example?

Me: Well, no, I meant....

Chris: Well, good. Because if you are encouraging me to steal, I'd have to report you.

Me: Okay, crap. Well, IMAGINE you have a bike...

Chris: Is this the same bike I just stole? Or did I buy it? And what color is it?

Me: Uh, you bought it and it's green. Kind of like the one you always wanted as a child but I never bought you.

Chris: Well, I don't like green. I'm glad you never bought it. Can my imaginary bike be blue?

Me: Anyway, so the bike has handlebars that steer the bike wheel, right. And when the handlebars go kittywampus you can't steer. So it's like a car. The two wheels in the front steer the car and the steering wheel controls that.

Chris: So our car has three wheels? Or five, really? And who the hell says ‘kittywampus’ anymore?

Me: Sigh.

Chris: No, please. Go on. This is interesting.

Me: Well, car hits pothole, alignment goes to hell, you fight the steering, can't brake properly, tires wear faster, and gas mileage goes to hell.

Chris: So, how is that like the bike?

Me: Forget the bike.

Chris: But I just bought it!

Me: Forget the bike. You don't need it.

Chris: Good, because I have you to drive me everywhere.

Me: .....

I saw this car outside of the ABC store today. As a testament to my outstanding character, the following immediately came to mind: 

1. You're drunk.

2. You fumble with getting the keys in the lock and drop the keys.

3. You bend (fall) over and mash your face along the car door on the way down.

4. The door opens.

If providers are under the gun from having patient satisfaction tied to reimbursement then shouldn't Medicare/Medicaid recipients have continued coverage tied to provider satisfaction?

Non-compliant? No soup for you!

Didn't lose the weight? No soup for you!

Still smoking? No soup for you!

Fourth kid on Medicaid? No soup for you!

Seriously.

Why do the "powers that be" punish providers for supposed substandard performance but are unwilling to put performance standards on patients? Especially the ones on the taxpayer dime?

Patients need performance standards, too.

Seen in a patient chart today:

"I don't want a stress test, I don't need one! If I have a heart attack, let me go!"

Later in the chart:

CODE STATUS: FULL

Anything is possible!

Seen today in a provider note:

"Time spent providing critical care possibly 45 minutes."

Hmm. Well, possibly you will get paid and possibly you won't.