The Maze – Pt 6
The Nigerian Health Care Plan

This is a continuation of a series on medical coding, billing, and reimbursement.

Previous posts are here:

See no evil
OK, I have a business deal to offer you:



With due regards, I take the liberty to contact you for an urgent business transaction which will be of immense benefit to all parties concerned. I am Mr Kingsley Chiugo, the Chairman of the contract Tenders Board of Nigeria National Petroleum Corporation, (NNPC).

My committee has the responsibility for the recommendation and award of contracts and supplies for the NNPC. In the course of our assignment, we did over-inflate the contracts for some supplies to the NNPC as a result of which the sum of USD $25.8m (Twenty five million, Eight Hundred Thousand United States Dollars only) is now outstanding. The original contractors who executed the jobs have since been fully paid off, leaving this outstanding sum. Unfortunately, we as civil servants are not allowed to own or operate a foreign account and it is also not possible for us to withdraw the money here locally.

We therefore need your kind assistance to transfer this outstanding sum of USD $25.8m to your account anywhere very safe. We shall compensate you with 25% of the funds for your assistance after the transfer. We the officials here shall have 65% while 10% will be set aside for any incidental expenses.

Oh, wait–you know about that one, and you’re not interested… OK, so here’s another–and this one’s for real:
Continue reading “The Maze – Pt 6
The Nigerian Health Care Plan”

The Epiphany

streamIt’s time for a change. A big change.

The days–once energized by the excitement of a remarkable profession, the joy of independence and self-sufficiency, the satisfaction of skills finely executed and a business well-run–those days, those same days, are increasingly a grinding chore, a tedium too often, their life-joy ever sapped by the parasites which at first merely annoy but by attrition rob their host, a few corpuscles at a time, of its very life.

I love my profession. It is a love which has changed much since the first flush of excitement in solving a difficult medical quandry, mastering a new technical skill, or acquiring the seemingly boundless knowledge and insight which medicine luxuriously provides to those who pursue it. Like a long and comfortable marriage, the excitement fades while the satisfaction deepens, sending down roots into the soul, drawing cool refreshment upward while enriching the very soil from which it draws life. The thrill of the disease mastered, the new technical skill first practiced, the immense satisfaction of a difficult surgery completed without flaw or blemish for the first time–these great joys do not pass away, but by their nature, like first love, temper themselves as mastery and repetition make their novelty fade. In their stead–though such accomplishments still bring quiet joy–comes a deeper and more profoundly satisfying sense of intimacy with the profession and the souls it touches. There is great indemnity in knowing that you have mastered the skills to tackle and conquer the challenge your patient brings to you–but far greater is the satisfaction, the deep joy and humility, which comes from having touched another soul in their moment of need, to have experienced in some measure their pain and futility, and then by skill and grace to provide a measure of relief and hope where none previously existed.

The satisfactions of this profession, now over 30 years my companion, today come in ways little experienced nor anticipated in its fervent youth. Far deeper now is the richness of a lingering conversation with an old patient, their acute crisis long passed, as we wander conversationally to common struggles and new experiences not even distantly related to health–yet paradoxically intimately bound up in it, in the well-being of us both. For to share friendship, commonality, mutual struggles, trust, laughter–this is to tap into the very heart of man as wandering pilgrim in the rich but treacherous lands we call life. Deep is the satisfaction of a surgery performed, not with the flashy cockiness of bright new skills, but with the weathered elegance of a task mastered through countless repetitions, endless subtle variations having been tested and proven to strive for an ever-receding perfection, just out of reach. It is a period of life in which one will say, at day’s end, that you have done well–having done nothing spectacular, nor been applauded by others, nor even appreciated by those who have benefited by the grace of years’ experiences, but rather have made a small difference, touched a life, changed a world.

Yet the brook which sparkles in the broken sunlight of forest trees, whose rushed whispers touch the spirit and excite the soul, both polishes the stone smooth and erodes the sandy soil with harsh, relentless abrasion. The solid ground is no match for the raging stream, which carves deep and jagged furrows in its frenzied rush downwards.

Each time an insurer sends my patient a letter, justifying their non-payment by defining my care as “medically unnnecessary,” the corrosive effects of this erosion is felt. Every time an employee repays generosity with greed, the soil is scored more deeply. Each agonizing case, fought with sleepless nights and troubled dreams, where best efforts yield bad outcomes and visions of lawyers and depositions haunt you like possessing demons, yet more of your bedrock is stripped away. Each mindless federal regulation, each legitimate payment denied and appealed, each illogical form demanded, consuming endless clerical hours without purpose or renumeration, erodes the joy and stifles the satisfaction of a noble profession, carrying you yet more distant from the headwaters which first drew you in.

The attack is relentless, as it is subtle. Physicans become “providers”; patients become “clients”; covenant becomes contract. Governments assume you are fraudulent and demand you prove otherwise. Hospital priviledges become hospital obligations, as their massive bureaucracies heap on unfunded mandates and endless requirements, camouflaged as “quality measures” but designed to utilize their indentured staff as free labor to satisfy yet another federal law or executive marketing decision. And the paper: cancer staging forms, mandated so the hospital can market itself as a cancer center; work release forms which defy logic and force square disease pegs into round punch holes; and endless mountains of charts to dictate, dictations to sign, reports to review, lab to compare and assess. Yes, much of this is the normal stuff of any job or profession–but its quantity has become so massive, and its rationale so perverse and distorted, as to starve the oxygen from all other priorities. We have become slaves of paper rather than servants of patients.

Last week, as I stared at a huge pile of undictated charts, unreviewed lab, scanned images to organize and import into the EMR, dozens of urgent emails demanding immediate action on matters trivial, and a pile of ill-organized detritus representing both wheat and chaff of running a business, I had an epiphany: something must change. Many things must change, in reality–but the process must start. I must recapture the joy, the satisfaction of this profession, no matter the cost.

Physicians are handling the devolution of their profession in many ways. Many who can are retiring early, seeking other careers, changing fields, moving to another state or form of employment. Many who cannot or will not pursue such solutions become fatalistic, depressed, sullen, and resentful, slogging through their joyless days, counting the minutes until they, too, can leave or retire to a measure of peace which recedes faster than the days pass. Others take the quick fix: the drink, the drug, the affair, the new Porsche, the trophy wife. Such measures kill the pain just before they kill the spirit, leaving nothing to give, emasculating the very energy from which the profession derives its life.

I am no stranger to many of these things: for years, increasingly disenchanted with the profession, I sought relief in dreams of new careers and the countless escapes which medicine provides through easy excuses and hard money. None satisfied, nor even came close; the more I hoped for relief, the more trapped and unhappy I became. My last epiphany came–as so many seem to–with the subtlety of a bomb, as looming disaster mandated fast change and a degree of faith and trust I had never before found within. Yet while fear can destroy or paralyze, it can also transform, and something far beyond my feeble means transported me to a new place little imagined and most unplanned. It has been a good place, a resting place, where the joy of my calling could once again resurface.

But that which is static dies–and this is nowhere more true than in the spirit, where comfort and routine deaden the heart. And so change–yet more change–must come.

Vocation–an old term, rarely used outside seminary and sanctuary today, but in truth that to which we all must all answer: the calling, the direction, the purpose which ennobles the effort, guides the spirit, and gives peace in the torrents and whirlpools of our passage down to death yet up to God. And to maintain the purpose, the calling, the vocation, there must be change. Almost ironically, to stay on course we must often change course. In my last epiphany I found in my profession my vocation–although this very profession was worn and weathered with years of purposeless passion and pointless pursuit. In this epiphany, this impending change, must come greater focus–not only on profession, but patients, and family, and friends, and spirit.

Change comes hard for most, I suspect, but particularly for those who have embraced this profession. For when we change, we change not only ourselves, but those around us–employees, patients, peers, and family must all be carried along with us, or lost in the swirling currents which can swallow the unguided and break the rigid, weak and feeble dams in their path.

And so, once again, it is time to step out in faith, to take a path whose direction remains unknown, to follow that still small voice so easily shouted down in the crush and rush of a world in such a great hurry to go nowhere, to accomplish nothing. It is a journey, like those before, of both fear and faith.

Let that journey begin.

The Maze – Part 5
Medical Coding: Compliance Penalties

This is a continuation of a series on medical coding, billing, and reimbursement.

Previous posts are here:


As most folks still drawing breath know, health care spending is rising at an alarming rate. The reasons for these spiraling costs are manifold: the introduction of expensive new technologies; an aging population; the detachment of financial responsibility for health care from the individual and positing it with employers and the federal government–just to name a few. The health care system in the U.S. is highly complex–scientifically, socially, and financially–and therefore finding workable solutions to such problems would be daunting even in a perfect world. But in a political world, creating functioning complex compromises, or fundamental redesign of programs, payment methodologies, and incentives, has become an utterly unachievable goal. So when constituents demand an instant, painless “fix” for skyrocketing budgets and health insurance premiums, there is one apparition which can always be called forth like Hamlet’s Ghost: stamping out fraud and abuse.
Continue reading “The Maze – Part 5
Medical Coding: Compliance Penalties”

The Maze – Part 4
Medical Coding: Compliance Programs

This is a continuation of a series on medical coding, billing, and reimbursement.

Previous posts are here:

GorillaThere–glad you’re back. Hope you enjoyed your lunch. I know after a meal we all tend to get a little drowsy. So to keep you from dozing off, I thought I’d tell a really, really scary story.

A number of commenters have asked the question, in so many words: “How did physicians ever allow this crazy system to come to pass?”

Good question.

And the answer is easy: when you dance with an 600-pound gorilla, the dance ain’t over ’til the gorilla says it’s over.

The gorilla, of course, is the federal government, and the dance, the provision of health care services covered under federal programs such as Medicare and Medicaid. For most medical practices treating adult patients, Medicare constitutes a significant percentage of total patients in a practice–and therefore a substantial percentage of income. One cannot accept federal reimbursements for medical services without being subject to federal regulations and restrictions. Since the vast majority of patients over the age of 62 are covered by Medicare, you’re pretty much stuck with the gorilla. She ain’t pretty, but she’s the only gal available–and she sure can dance.
Continue reading “The Maze – Part 4
Medical Coding: Compliance Programs”

The Maze – Part 3
Medical Coding: Diagnosis Coding

This is a continuation of a series on medical coding, billing, and reimbursement.

Previous posts are here:

mazeI had planned to move on to federal monitoring and enforcement of health care reimbursement, but decided I would be remiss not to spend a little time on the diagnosis system and how it relates to medical billing and reimbursement. For those of you weary and bleary-eyed from the last two posts, this one will be a bit less insane–our friends over at ShrinkWrapped, Dr Sanity, or SC&A would probably diagnose this system as merely neurotic, rather than psychotic. But crazy it is, nevertheless.

When you submit a claim for health care services to a federal agency (e.g. Medicare or Medicaid) or a private insurance company, you must identify not only the service which you have provided, but the reason for which the service was performed. To do this, you use a system called the ICD-9 codes. ICD stands for the International Classification of Diseases, a system initially developed by the World Health Organization for epidemiology purposes–in other words, to track and categorize diseases in different parts of the world. The “-9” part indicates the revision number, and the ICD-9 has been around for quite a few years–at least 8 to 10 years to my recollection. The system, designed for tracking epidemics and targeting world health resources, has been adopted by health care payors to standardize reimbursement, similar to the CPT service codes spoken of in the first two parts of the series (CPT=current procedural terminology, the codes used for procedures and E&M services). There are plans for an ICD-10 which have been bandied about, but their implementation date is uncertain.

If you’re thinking that a system designed to send vaccines to Africa and track outbreaks of Dengue fever may not be ideally suited to health care reimbursement in the U.S., you’re showing great promise as a student of medical coding.
Continue reading “The Maze – Part 3
Medical Coding: Diagnosis Coding”

The Maze – Part 2
Medical Coding: E&M Guidelines

mazeGood–you’re back. Grab some coffee and head for your seats–the captain has turned on the seat belt sign, since there’s some rough flying ahead.

Before the break, we were discussing medical coding, billing, and reimbursement, in particular how procedures (surgical and otherwise) were handled. Now for the real fun: how do you decide the proper code for so-called cognitive services: the collection of medical history and data, physical examination, test and diagnostics, and medical decision-making? In coding parlance, these are called evaluation and management services, or E&Ms.

An encounter with a physician–in or out of the hospital–involves two broad tasks: information gathering and decision-making. On the information side, physicians use medical history (information about your present symptoms and illnesses, past illnesses, habits, and genetic risk factors); observational information, primarily from the physical exam; and diagnostic studies such as lab or x-ray. On the decision-making side, there are deductions about what problem or illness you have; judgments about the need for additional diagnostic studies or consultation by other physicians; and decisions about treatment such as medication or surgery.

As you can imagine, there are countless variations on this process, both in terms of the extensiveness of the evaluation, the investigative methods, and the complexity of the decision-making process. And so you can assume that quantifying this process objectively, in order to establish proper payment for services is a daunting task indeed. So the Feds, in conjunction with the AMA, came up with “guidelines” for establishing the level of E&M services–actually, 2 sets of guidelines, one in 1995, and a second in 1997. The 1995 guidelines were widely criticized as being too vague and difficult to interpret–a problem which was solved in 1997 by massively increasing their complexity. (Never, ever, suggest to the government that its regulations aren’t clear enough–the resulting deforesting required to supply paper is a principle cause of global warming).
Continue reading “The Maze – Part 2
Medical Coding: E&M Guidelines”

The Maze – Part 1:
Medical Coding: Intro & Procedures

Hedge mazeI won–I think.

George was a Vietnam vet, a grunt who served honestly and well. Drank hard and smoked, got hosed with Agent Orange like many, got discharged and went on with life. Settled down, stopped smoking, got married, a solid citizen.

In his early 50’s, he presented with an advanced, aggressive form of bladder cancer, the payback of choices both honorable and foolish. Too advanced for surgery, he underwent chemotherapy and radiation, and initially did well. At his interval cystoscopy–a visual exam of his bladder–I saw some changes that were troubling, suspicious for recurrent cancer. After the exam, we sat and talked–about the findings, the need for further evaluation with CAT scan, which was scheduled, and additional treatment options, including major surgery, should the cancer have recurred. It was a good 30-40 minutes after the exam before he and his wife left. That was last July–nine months ago. I just got notified that I will be paid for his visit.

Now, this is not really about George–it’s about his insurance company, and the Feds, and many other insurance companies just like his. And to explain the issue, and how insane and perverse it is, you will first need to go to school. So take your seats, sharpen your No. 2 pencils, open your spiral notebooks, and listen up: I’m gonna teach you about how George’s medical charges and billings–and yours, and millions like you and him–really work. This course is called Medical Coding and Reimbursement 101. Ready? I knew you were (except for those who thought you were auditing Transgendered and Feminist Perspectives on War, Rape, and Postmodern Literature: next classroom, please). So lock the door — no smoking, you in the back–and let’s get started.
Continue reading “The Maze – Part 1:
Medical Coding: Intro & Procedures”

The Stallion


Vignette #1: His surgery went smoothly–dozens of sutures too fine for the unaided eye, reconstructing his vasectomy to restore fertility. The outcome was promising, the young couple quite excited at the possibilities. His recovery was uneventful, so his call a week or so later was a bit of a surprise.

“How’s everything going?”

“I feel great!”

“Good. Any problems or questions?”

“Doc, you said I should wait ten days before we have sex.”

“Yes, that would be a good idea.”

“Is there any problem with … toys?”

Toys … Teddy bears? Legos? Fire engines?TOYS! … Oh.

Don’t ask.

“I … don’t think so … just don’t do anything … crazy, ya know?”

“OK, Doc, I won’t. Thanks!!” Click.

Vignette #2: She was good natured, but quite demented–and looked every day of her 84 years. She sat, her daughter beside her, her plasticine smile frozen softly in contemplation of some other cosmos. I struggled to elicit a history of her illness–a task well beyond her cognitive means. Finally, having coaxed all the information I could, I advised her it was time for a physical exam.

I stood up, and turned to leave the room so she could prepare in private.

She turned to her daughter, calling her by the wrong name: “What did he say?”

“He wants you to get undressed for your exam.”

“Oh, sweetie, I’d love to take my clothes off for him!”

The door latched softly behind me, entombing forever the fervent hopes and feverish dreams of midlife mojo.

Vignette #3: He was, by any standards, physically unassuming: thinning, curly hair, slightly dishevelled; thick black glasses clashing harshly against a pasty cratered complexion; picket-fence teeth weathered by smoke and caffeine; gaunt not from aerobic workouts but neurotic hyperactivity. Whatever your first impressions, one thought would never come to mind:

Chick magnet.

He was younger than most–early 50’s–but his prostate obstruction was severe, requiring surgery. He arrived at the office two days later to have the catheter removed.

The balloon deflated, the catheter slid out easily and painlessly. I was not prepared for the question.

“Will this make me sexy?”

Sexy. Sexy. Say wha…?!


“Yeah–I’m quite the stallion, ya know…”

No, I didn’t. I really, really didn’t.