Thanks all for the clarifications. I now realize that there are CPT and ICD-10 codes and that they are different. I probably heard the doctor talk about a diagnosis code and then heard the staff ordering a test and using different terminology. As a patient just trying to keep up with what is going on around me, I think I am easily confused.
This is the bane of my existence. There are tests I want to order that aren’t approved all of the time. My staff knows all of the “tricks” . Want a screening blood count to check for anemia? Better have a valid diagnosis. Joint pain works. Ever tried to argue with a 90 year old that “you must have pain somewhere, just tell me so I can get the test”. Everyone wants to be screened for vitamin D. I can screen you if you have a documented low vitamin D level. Want to check your vitamin B12? Vitamin B12 deficiency doesn’t cut it unless you also have anemia but “unspecified deficiency of B vitamins” does. That is why I get patient complaints saying “ why do you list high cholesterol as a problem when it is under good control with diet and exercise?” I tell them that if I remove the diagnosis, Medicare will not allow me to check it ever again. If I want to continue to monitor it, you will see the diagnosis of elevated cholesterol ( with a note-controlled with diet and exercise). And don’t get me started on the surgeons and their preoperative orders! They all want a PT/PTT ( clotting factors) and request I draw them along with the other preoperative labs. They’ll add a code to the request, such as rotator cuff tear, which they can use to justify their surgery but will in no way, shape or form justify a PT/PTT. I’ve basically given up on this one. I code it as presurgical screening, let the patient know they will be charged by the lab and tell them to take it up with the surgeon. Meanwhile, the lab keeps sending me forms saying that they need a valid diagnosis for the test and the patient complains that the surgeon told them that they needed the test for surgery and that I was provided with the diagnosis ( again, not a valid one for that test). And don’t forget that unless a Medicare patient signs an Advanced Beneficiary Notice stating that they were advised that the test will not be covered, the ordering doctor ( which would be me, not the surgeon) will be responsible for the cost. So…
tl/dr: sometimes we have to list a lot of diagnoses in order to get your tests covered.
Grumpy adult docs -
Do you participate in many Medicare Advantage plans, and if so how much effort are you placing to be sure you have captured all of the most specific hierarchical condition category (HCC) diagnostic codes that improve your Risk Adjustment Factor (RAF)?
It seems like a very big deal on adult side in my group.
The short version for those unfamiliar is that Medicare pays a group based on the statistical risks for the patient population covered, which they determine based off of which HCC codes have been entered that year. Decent dollars follow more precise (not inflated) coding. Depression unspecified does not do much for the RAF while major depression single episode mild does. Specifying that the patient does not just have diabetes but also has diabetic retinopathy matters. Noting exactly which level of CHF, class of obesity, so on.
I’m not sure if this is part of what the OP sees, the annual documentation of the active HCCs as precisely as possible to optimize RAF?
Hey, that’s pathologists’ income you’re trifling with! But yeah, injudicious use of scans turns up a lot of nothingburgers that wind up being biopsied, with the potential of physical or psychological harm to the patient.
Overreliance on test results with inattention to the frequency and significance of false positives can be costly, and not just in terms of money spent chasing down non-diagnoses.
Some of the worst physician offenders practice in the realm of so-called “functional medicine”.
And we patients with our access to the Intertubes don’t help, when we come in saying “I read that this could be…”
20 years ago (!) I had a ganglion cyst removed from my foot. After excision, the doctor showed it to me. I said, “Will you send that to the lab?” and he said, “Absolutely!”
When I saw him for followup, he said the lab test was of course normal and that he had been 100% sure it would be, but that as a defensive practice, he’d been taught that if a patient EVER says “Will you send that to the lab?” the ONLY possible answer is, “Absolutely!”, because if that’s the one time he’s wrong, it’s bad; if it’s the one time he’s wrong AND the patient had asked the question, he’s toast.
Imagine when patient asks, “Could this be [extremely rare and unlikely condition requiring an expensive test]?” – same rule applies.
This isn’t the doc’s fault, or even (for a change) the insurance companies’: it’s our tort system.
Mmm, torte.
My favorite patient request: “check my hormone levels “. I have to point out that there are hundreds of hormones in our bodies. Do they really want to check them all?