Medical Gluttony

Current Issue

ICD 10 replacing ICD 9 codes on October 1, 2015 - Part II

ICD

There are two related classifications of diseases with similar titles, and a third classification on functioning and disability.

The International Classification of Diseases (ICD) is the classification used to code and classify mortality data from death certificates.

The International Classification of Diseases, Clinical Modification (ICD-CM) is used to code and classify morbidity data from the inpatient and outpatient records, physician offices, and most National Center for Health Statistics (NCHS) surveys.

NCHS serves as the World Health Organization (WHO) Collaborating Center for the Family of International Classifications for North America and in this capacity is responsible for coordination of all official disease classification activities in the United States relating to the ICD and its use, interpretation, and periodic revision.

The Collaborating Center also is responsible in North America for the WHO Family of International Classifications, which includes the International Classification of Functioning, Disability and Health (ICF).

International Classification of Diseases, Ninth Revision (ICD-9)

The International Classification of Diseases (ICD) is designed to promote international comparability in the collection, processing, classification, and presentation of mortality statistics.

This includes providing a format for reporting causes of death on the death certificate. The reported conditions are then translated into medical codes through use of the classification structure and the selection and modification rules contained in the applicable revision of the ICD, published by the World Health Organization. These coding rules improve the usefulness of mortality statistics by giving preference to certain categories, by consolidating conditions, and by systematically selecting a single cause of death from a reported sequence of conditions. The single selected cause for tabulation is called the underlying cause of death, and the other reported causes are the non-underlying causes of death. The combination of underlying and non-underlying causes is the multiple causes of death.

The ICD has been revised periodically to incorporate changes in the medical field. To date, there have been 10 revisions of the ICD. The tenth revision is due to be implemented next year in 2015.The years for which causes of death in the United States have been classified by each revision are as follows:

Revision

Years Covered

 1st

1900-09

2d

1910-20

3d

1921-29

4th

1930-38

5th

1939-48

6th

1949-57

7th

1958-67

8th

1968-78

9th

1979-98

10th

1999-present

At the present time making a diagnosis, remains a physician’s domain.  However, inroads are being made. Sometimes these are being made without our awareness. When my present insurance biller started several years ago, she said I could not and had not been paid for my pulmonary function tests. I needed to place “wheezing” as a diagnosis or I would continue not to be paid. So my lack of being reimbursed for years depended not upon an additional diagnosis, since wheezing is a physical finding in the diagnosis of asthma and emphysema, and not a diagnosis in and of itself. I had been denied being paid for an important pulmonary procedure in my specialty of pulmonology, all because of a medical illiterate imposing his or her understanding of healthcare or medicine on those too busy to cross-check every item of coding. In this case an erroneous ICD code was required to pay for a valid CPT code which meant that a correct ICD code negated a valid CPT code which, in turn, cancelled payment for the pulmonary function test.

One of the reasons for the ICD codes was the correct coding of the cause of death. Physicians think in a pathophysiologic sequence of causality. For instance diabetes may cause renal disease which is an etiology of hypertension, which can be the cause of renal failure, stroke and death. If that is the sequence, the physician would normally list them as such. Lay medical examiners, may rearrange this sequence in a non-causative sequence. Or they may insert benign hypertension as causative of death and a sequence to diabetes in the absence of renal disease.

With all these intrusions into the practice of medicine, the massive coding changes of October 1, 2015, may be the best time to close your practice to avoid the risk of coding errors, or errors in coding your patients by medical illiterates, even though not caused by you. In an increasing litigious society, with prosecution for irrelevant variations of irrelevant medical issues, retirement by the date the ICD 10 codes are implemented may prevent retirement to a prison cell.

Those places with cement walls, floors and bars in place of windows sometimes get very cold in winter and warm in summer. Not the most comfortable or healthy retirement villa. But it does help you remember that it all started with an accusation of gluttony for up-coding when you were totally unaware of it.

To be continued next month . . .

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Medical Gluttony

Previous Issue

ICD 10 replacing ICD 9 codes on October 1, 2015

International Classification of Diseases

Using numbered codes for diagnosis make cataloging disease and coding the cause of death easier and more accurate. These are the ICD codes (International Classification of Diseases). ICD 1 began in 1900 and the current ICD 9 is scheduled to be replaced by the ICD 10 in October 2015. The magnitude of the changes can be seen in the ICD 9 having about 16,000 diagnostic codes and the ICD 10 will have about 68,000 diagnostic codes. This was to be effective in October 2014. Because insurance companies, medical billers for large medical groups could not meet the deadline, Obamacare delayed the implementation to October 2015. The possibility for error has increased dramatically. Errors in coding can be interpreted as fraud, especially if there is a financial incentive, and can be prosecuted and lead to stiff fines or sanctions. Hence, the one year delay has added an additional year of practice for many physicians and surgeons who will close their offices on the date of implementation.

Using a numbered code for each medical or surgical procedure helps define the procedure for greater consistency. These are the CPT codes, Current Procedural Terminology, which define the time and work involved with each procedure required for the diagnosis and management of each recorded ICD code. These have been spelled out in great detail with E & M (Evaluation and Management) descriptions for all medical and surgical procedures. The risk for errors with CPT codes is much greater and the penalties more severe than for ICD errors since CPT codes are tied to reimbursement. If the doctor’s description of his/her medical evaluation or procedure doesn’t support the code, then he/she is guilty of fraud. Thus a doctor that is very busy and his dictation or record keeping is delayed, which can cause an oversight, an error in recall or a total omission should that chart not make it back to his desk, he/she would be guilty of fraud if that record were reviewed.

After the CPT codes were change about a decade ago, a physician in our community who had primarily a nursing home practice was reviewed. He would make rounds on these difficult patients with stroke, decubiti ulcers, dementia, and other debilitating diseases on a monthly basis as required by MediCaid. Many of these patients had lost their ability to speak. Hence, much of his medical history was obtained from the nurse or the patient’s record and he would record his exam. Some of these nursing home patients had severe contractures, buttocks with decubiti ulcers wrapped in soft cloths, taped, which made his physical examination difficult and less than complete.

When he was reviewed, as he faced the medical reviewer, a US attorney, and a peace officer, he was told that he used the wrong CPT codes and therefore, his reimbursement was greater that it should have been. He stated that he did not understand the new codes and left it to his staff to figure out which to use and he continued to do the same amount of work and continue the same charges he had used prior to the code changes.

He was then asked if he understood the codes after their explanation and he said “yes” and he was sorry and would not do that again. According to this physician he was then asked to sign an agreement that he indeed had used the wrong codes and would use the correct codes in the future. As he explained it to me some two or three later, he signed the admission of having used the wrong codes, and was promptly handcuff by the officer, and led off to jail. He spent the next 22 months in prison. Although he was relatively young, he should have been able to practice for another 20 or 30 years, except now as a felon, he lost his license, his home, and all his assets to attorney’s fees.

He did not think it was gluttony since his charges and work were the same, but the FEDS did. And he did time, is considered a felon, and no longer is a physician and no longer can vote.

Some physicians felt he did nothing wrong, he charged his usual and customary fee for his service, both before and after the code changes, did not commit fraud, but still became a government manufactured white crime criminal losing at least a half million dollars his father invested in his education and ended up as a day laborer.

Tune in next month for a continuation of coding in Section V.

So if you’re near the time to close your practice, seriously consider closing it on Oct 1, 2015.

I will be closing mine on the date that ICD 10 is implemented.

I don’t want to spend the last decade of my life in prison.

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Medical Gluttony

Past Issue

Social Security Disability Insurance Costs More than Medicare

By Tad DeHaven, the Cato Institute, August 6, 2013

Social Security Disability Insurance (SSDI) is one of the largest federal programs; it is also one of the most troubled. The program's expenditures have doubled over the last decade, reaching an estimated $144 billion this year. Spending has risen so rapidly that SSDI's trust fund is projected to be depleted just three years from now, says Tad DeHaven, a budget analyst at the Cato Institute.

SSDI was originally created as a modest safety net aimed at severely disabled workers who were close to retirement age, but Congress has expanded benefit levels over the decades and eligibility standards have been greatly liberalized.

  • The result is that people capable of working are instead opting for the disability rolls when confronted with employment challenges.

  • Once on the disability rolls, experience shows that individuals are likely to remain there, which is bad for the individuals, taxpayers and the economy. 

The process for determining eligibility for disability insurance benefits has become a bureaucratic nightmare.

  • Applicants often pursue a lengthy and litigious appeals process if their initial applications are denied.

  • And there is a growing reliance on subjective considerations in evaluating claims, which has exacerbated the difficult task of determining whether an individual is truly "disabled."

  • Specialty law firms working on a contingency fee basis have taken advantage of the complex system and its inconsistencies to reap a financial bonanza at taxpayer expense.

SSDI has become financially unsustainable and economically damaging, and policymakers should pursue major spending cuts to the program. They should also explore the potential to transition responsibility for disability insurance from the government to the private sector.

If Americans are not becoming less able to work because of health problems, why are the disability rolls increasing? Economists David Autor and Mark Duggan note that "the rapid growth of Disability Insurance does not appear to be explained by a true rise in the incidence of disabling illness, but rather by policies that increased the subjectivity and permeability of the disability screening process." Similarly, economist Richard Burkhauser calls the explosion in the number of people gaining federal disability benefits a "policy-driven epidemic."

Source: Tad DeHaven, "The Rising Cost of Social Security Disability Insurance," Cato Institute, August 6, 2013.

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Medical Gluttony

Past Issue

Medical Autonomy

There has been some confusion in this era with Personal Health Records with getting the patient more involved in his or her own care. Some patients have interpreted this as going to any doctor they feel they need at the moment. They do not see their personal physician as being their managing partner—but just a person they can see when all else fails and they don’t know which doctor they should see next. They don’t feel that cost should be a factor. They have no concept of the costs involve. They consider it as just another office call with a new or different doctor. One patient this week said it didn’t matter since she had Tri-Care, which allowed her to seen anyone she desires without authorization. 

She had seen two new physicians since her previous evaluation. She had developed a cough with the phlegm clearing after a course of antibiotics. However, it did not clear her otherwise hacking cough. The allergist had done a pulmonary function test but she had no idea how well she did or what it showed. But she did begin allergy injections which over two months had no effect on her cough nor was it expected to do so in two months.  The printout from our HMO suggests that each consultation, which usually requires additional lab tests, x-rays, or procedures, adds $1500 to $3500 to that patient’s medical costs.

She also had two urgent care visits since her last evaluation in our office. Urgent care center evaluation is by another new physician who makes a stab at the diagnosis in the minimal amount of time without benefit of the patient’s medical records. Hence, these evaluations have minimal value depending on how many tests previously done have been duplicated. This is also a costly and essentially unnecessary expense.

She also had a hospital emergency room visit and was given another antibiotic. In the absence of any phlegm, this also had no significant effect on her cough. She developed nausea and vomiting the second day and call the Emergency Department. She was told there were no other antibiotics and she should see her personal physician.

The hospital Emergency Department visits start at $600 in our community but frequently can be as high as $9000. The ER doctor does not have the benefit of the patient’s medical file which may have been developed over the course of years with numerous tests, x-rays and probable procedures which the patient may not recall during an emergency evaluation, and even if recalled, is not able to give a medically verifiable result.

As a Pulmonologist I felt somewhat frustrated to not have basic pulmonary data to confirm my diagnosis to chart her treatment. Should I repeat the PFT or treat her empirically? Her cough of several months duration, persisting through two doctors, two urgent care centers, and one emergency room, had not stopped the coughing.

The diagnosis should have been obvious. In a lady with allergic rhinitis (hay fever) who develops a cough, it more likely than not is allergic bronchitis sometimes called cough variant asthma. Examination did confirm asthma. She did not have her albuterol inhaler with her and didn’t have any idea that she should carry it with her at all times.

So we used a new inhaler in our office. She was advised to exhale fully, open her mouth wide, and take a deep breath as I gave her an albuterol spray which she inhaled. I quickly reminded her that she must hold her breath for 30 to 60 seconds. If she exhaled the albuterol, it obviously would not do her any good outside her lungs. She was able to hold it for 45 seconds. She was then given the second inhalation of albuterol and was able to hold it for 60 seconds.

She had not further coughing during the remainder of her evaluation.

She was advised in the future to see her personal pulmonologist before the $10,000 to $15,000 she cost her insurance company over the past two months which are the ones who pay their Blue Cross premiums for such gluttonous use of health insurance which then increases their premiums unnecessarily. She already had an albuterol inhaler and we advised her to use every time she coughed. Hence, our $150 office call which required no further prescriptions was more effective than the $15,000 she had incurred.

We reminded her that we are always able to see established patients with 48 hours of their call and none of her health care visits were emergencies. In fact, none of her health care visits were effective.

She had not told any of these doctors who her personal physician was. Hence, we had no reports from any of them and so they were irrelevant to her. She was told to have a report in our office before her next visit from all her doctors or we would withdraw from her care. We would not be party to such a flagrant abuse of health care resources.

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In this case it would have saved more than $10,000.

 

Medical Gluttony

Past Issue

Obama Administration: Largest Tax Hike since WWII

Recently, April 15th, so-called "Tax Day," served as a reminder that our federal government takes more of our money each year to fund a multitude of things not within its constitutional authority or purposes.

President Obama bragged recently that our deficits are coming down at the fastest rate in 60 years. And it is true: deficits as a percentage of gross domestic product (GDP) are falling faster under Obama than they have at any point since the end of World War II, says the Washington Examiner.

  • However, when the federal government's deficit fell from 30.3 percent of GDP in 1943 to a 4.6 percent surplus in 1948, the change was almost entirely due to deep spending cuts.

  • In 1943, federal government spending made up 43.6 percent of the economy. By 1948, that spending sunk like a rock to 11.6 percent.

  • And yet, despite forecasts of economic doom by Keynesian economists, the U.S. economy boomed after WWII.

  • Taxes actually fell during this period too, from 20.9 percent of GDP in 1944 to 16.2 percent in 1948.

Fast forward more than 60 years to today, and taxes are rising faster now under Obama than they have under any other president since WWII.

  • When President Truman came into office in 1945, federal taxes were 20.4 percent of the U.S. economy. When he left office in 1953 they made up just 18.7 percent.

  • President Eisenhower then lowered taxes even further to 17.8 percent by 1961, and President Kennedy lowered them further still to 17.6 percent.

  • President Johnson then raised taxes for his wars on Vietnam and poverty to 19.7 percent.

  • President Nixon then cut taxes to 17.9 percent by 1975, before President Ford raised them to 18.5 by 1977.

  • President Carter raised taxes even further to 19.6 percent, before President Reagan cut them to 18.4 percent and President Bush cut them to 17.5 percent.

  • President Clinton then raised taxes to 19.5 percent of GDP by 2001 before President Bush cut them to 17.6 percent in 2008. The financial crisis then sunk the economy, lowering tax collection to a post-WWII low of 15.1 percent.

  • President Obama's many tax hikes will send taxes as a percentage of GDP as high as 19.3 percent in 2015, before falling to 18.9 percent in 2017.

  • From 2009 to 2017, taxes as a percentage of GDP will have risen 3.8 points, a larger tax hike than any other American president since WWII.

Source: Conn Carroll, "Taxes Rising Faster under Obama than Under any Other President," Washington Examiner, August 7, 2013.

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Medical Gluttony thrives in Government and Health Insurance Programs.

Gluttony Disappears with Appropriate Deductibles and Co-payments on Every Service.

 

Medical Gluttony

Past Issue

Obama Administration: Largest Tax Hike since WWII

Recently, April 15th, so-called "Tax Day," served as a reminder that our federal government takes more of our money each year to fund a multitude of things not within its constitutional authority or purposes.

President Obama bragged recently that our deficits are coming down at the fastest rate in 60 years. And it is true: deficits as a percentage of gross domestic product (GDP) are falling faster under Obama than they have at any point since the end of World War II, says the Washington Examiner.

  • However, when the federal government's deficit fell from 30.3 percent of GDP in 1943 to a 4.6 percent surplus in 1948, the change was almost entirely due to deep spending cuts.

  • In 1943, federal government spending made up 43.6 percent of the economy. By 1948, that spending sunk like a rock to 11.6 percent.

  • And yet, despite forecasts of economic doom by Keynesian economists, the U.S. economy boomed after WWII.

  • Taxes actually fell during this period too, from 20.9 percent of GDP in 1944 to 16.2 percent in 1948.

Fast forward more than 60 years to today, and taxes are rising faster now under Obama than they have under any other president since WWII.

  • When President Truman came into office in 1945, federal taxes were 20.4 percent of the U.S. economy. When he left office in 1953 they made up just 18.7 percent.

  • President Eisenhower then lowered taxes even further to 17.8 percent by 1961, and President Kennedy lowered them further still to 17.6 percent.

  • President Johnson then raised taxes for his wars on Vietnam and poverty to 19.7 percent.

  • President Nixon then cut taxes to 17.9 percent by 1975, before President Ford raised them to 18.5 by 1977.

  • President Carter raised taxes even further to 19.6 percent, before President Reagan cut them to 18.4 percent and President Bush cut them to 17.5 percent.

  • President Clinton then raised taxes to 19.5 percent of GDP by 2001 before President Bush cut them to 17.6 percent in 2008. The financial crisis then sunk the economy, lowering tax collection to a post-WWII low of 15.1 percent.

  • President Obama's many tax hikes will send taxes as a percentage of GDP as high as 19.3 percent in 2015, before falling to 18.9 percent in 2017.

  • From 2009 to 2017, taxes as a percentage of GDP will have risen 3.8 points, a larger tax hike than any other American president since WWII.

Source: Conn Carroll, "Taxes Rising Faster under Obama than Under any Other President," Washington Examiner, August 7, 2013.

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Medical Gluttony thrives in Government and Health Insurance Programs.

Gluttony Disappears with Appropriate Deductibles and Co-payments on Every Service.

 

Medical Gluttony

Past Issue

Frequently not recognized by patient, family, hospital, or physician

The perspective of a pulmonary consultant occasional provides an overview of medicine. Recently a patient was referred for consultation of an emergency room evaluation. The family was very concerned over the report of a very abnormal chest x-ray.  The report indicated right middle lobe collapse, interstitial infiltrates, calcified pleural plaques, and possible pneumonia. 

I remembered him from previous consultations. He looked like a robust 70 year old Eastern European. He didn’t appear ill and looked about as I had remembered him. The son, who also served as the interpreter, re-expressed the concern of a serious and grave illness. Since his chart had been retired after five years of inactivity, a search of our computerized files found our previous consultations of 2001 and 2008.

As I perused my previous consultation, I read aloud my concern about his abnormal chest x-ray in 2001, how the patient had recalled that he had a similar abnormality of his middle lobe in Hungary in 1981, he had had a bronchoscopy which revealed a narrowed bronchus to the middle lobe, that biopsies were obtained and no cancer was found obstructing the middle lobe which is a common presentation of a middle lobe lung cancer. “But is the x-ray the same?” I stated that it is impossible to ascertain if they are identical without seeing the x-ray side-by-side on my viewing box, but that considering one radiologist reading the films in 2001 and a different radiologist reading the film in 2013, it would certain appear that they were describing essentially similar films.

“But dad is so much more short of breath,” he said. “Well then, why don’t we measure his pulmonary function and determine why he’s so short of breath.” I found his old PFT on my laptop and printed it out showing a mid-expiratory flow rate of 14% of normal, and then did a current PFT which showed the same flow parameter at 12% of normal. The son immediately mentioned that his dad had obviously gotten 2% worse. I pointed out that this was probably within the standard deviation of testing and was really the same value. The son breathed a sigh of relief and the patient just smiled broadly as if he never had any concern.

Looking over the 41 pages of emergency room testing, it was apparent this was well beyond the usual average of $9,000 for an emergency room visit and was more like a $20,000 relatively “non-transparent” charge. How can these costs be controlled? This has occurred over a long period of government meddling into physician work hours, giving ER evaluations greater latitude in charging Medicare, and lack of patient copayments and deductibility, all previously discussed in this column.  

Since the initial complaint was chest pain, and the initial electrocardiogram was normal, a 20% copayment on a $200 ECG may have satisfied the family that he wasn’t having a heart attack. If they had stopped the testing at this point when their 20% copayment was $40, it would have save Medicare more than $20,000 in costs. If the patient had gone to the same hospital emergency room where his first 2001 tests had occurred, the initial $250 chest x-ray could have been compared to the previous one and the 50 copayment may have satisfied the family and the $20,000 in hospital costs could have been contained. If the patient would have come to the same consultant in the office that saw him in 2001, a clinical diagnosis could have been made of no change. If the family anxieties could have been relieved at that point, then the whole $20,000 cost could have been contained. Continuity of care may be the biggest restrainer of health care costs increases.

But as long as the medical illiterate control the White House, the Congress, and the AMA, reason will never prevail.

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