Coding consult

It was the last straw. After years of getting poor reimbursement for Pap smears, I received an explanation of benefits statement that allowed just $4 for a Pap and handling. “This is unacceptable,” I said to Dalia, my office manager. “Call the insurer and find out what we’re doing wrong.”

The call came up empty. The claims rep promised to look into it and get back to us within 14 working days, but we knew we’d never hear from her again. “Someone must know how to bill this,” I said. “I can’t imagine my colleagues doing Pap smears for $4.” Then, I had an inspired thought: Who does more Paps than anyone else in our area? The gynecologists. “Call the Women’s Health Center, talk to their biller and ask her how she does it.”

Ann laughed when she heard we were still using codes 88150 for the Pap and 99000 for handling. “Those codes are obsolete. We haven’t used them for years,” she said. “We use the codes for preventive annual exams, 99384 to 99387 for new patients and 99394 to 99397 for established ones. We don’t bill for handling.”

Their charges for the exam were somehow stratified by age, as if doing gynecological exams on older patients was harder than on younger ones. I didn’t get it, but who was I to argue with success. “Dalia,” I said, “if these codes work, I’ll give you a raise.”

Then, I wondered how much money we were giving away to insurance companies by improperly coding for other services as well. “No wonder those guys are rich,” I thought.

A bold woman

Today is my mother-in-law’s memorial service. Ima died at the age of 80, trying to travel to southern California to attend her lifelong friend’s funeral. Halfway to her destination, in the middle of nowhere, she had the sudden onset of excruciating abdominal pain. After an hour of bearing it, she requested to see a doctor. The only hospital in the area had limited resources; an ER doc was on duty, but no surgeon was on call and the CT scanner was only available during the day. Ima arrived there at midnight.

Dr. Will had the collegiality to call me after his evaluation. “Ima has something serious going on in her belly. Her white count is 21,000, and she’s in a lot of pain. I’m having a hard time controlling it. She needs a surgical consult, but the nearest surgeon is an hour away. We could ship her by ambulance.” Knowing Ima’s wishes for no heroics and her likely refusal of surgery anyway, we made the decision to make her as comfortable as possible and scan her in the morning. After all, we still didn’t have a diagnosis.

The first CT scan looked almost normal, but one done several hours later showed signs that she had suffered a mesenteric thrombosis. She was getting worse; her white count had risen, and she was still in pain. I was eight hours away, so my wife, my sister-in-law and Ima had to make the decision. “We’re going home,” they said. Although the head nurse was obstructionist, the rest of the staff who cared for Ima were amazingly supportive and Dr. Will was a prince. They loaded her up with morphine while the girls made her a bed in the backseat of the pickup truck. Dr. Will even gave them his personal cell phone to use. He had essentially taken care of Ima since her arrival, and as she departed he had tears streaming down his face. “Haven’t any other patients done this before?” my wife asked him. “Yes,” he replied, “but none so boldly.”

Ima survived the trip home and died in her bed in the company of her dogs, friends and loving family.

Schooled!

A new face appeared at our weekly racquetball pick-up game. His name was Rick, he was from Oregon and he had only one question: “Are there any class-A players here?”

“We used to be class-A players,” I kidded, “but we got old. Now we’re over-the-hill players. But you’re welcome to play with us.”

Rick proved to be a good sport, and we paired him with our worst players for some doubles matches. His team won every time – and he hadn’t even taken off his sweats! After wearing out nearly everyone, he asked, “Is anyone up for singles?”

Everyone else begged off, but I was willing to be humbled. “Sure,” I said, “Let’s play.” I’ve always considered myself to be a decent player, having played the game for over 30 years. What I lack in power I make up for with finesse. Around the club, my nickname is Dr. Dink.

We played two games, and it wasn’t pretty. I lost 15 to 2 and 15 to 1. Rick always put the racquetball exactly where he wanted it to go. He sized up my weaknesses and played to them relentlessly. All of his hits were either passes or kills, and I was lucky to get any kind of rally going. When it was over, I thanked him for the lesson.

Then it occurred to me that the way I practice medicine is not too dissimilar from my approach to racquetball. I recognize my limitations, try not to exceed them, seek help from specialists when necessary and savor the lessons I learn from them because they make me a better physician. Pride may be acceptable on a racquetball court, but it has no place where our patients’ well-being is at stake.