An ICD-9 Story

Medical billing and epidemiology relies on a classification of diseases maintained by the World Health Organization. On the first of October, 2015, we will transition from ICD-9 to ICD-10, a major change that increases the number of available diagnoses from some 17,000 codes up to more than 155,000. In a strange cosmic twist, that’s the same day that most retails need to install readers for credit cards with chips or be liable for bad purchases.

With that in mind, I present a short story in ICD-9, with a translation into English.

It was E900.0. That, combined with E904.1 and E904.2, not to mention V69.4, is what led to 780.2. I admit it, I have V69.0 and V69.1. I usually sleep well, but that night was different, thanks to 780.55 due to 780.92. That morning I understandably drank 969.7, leading to 785.1. During E924.2 while E013.0 I felt 780.4. Stepping out I had 368.45 before I 780.2.When I was V49.89 after my E884.9. I had a 784.0, as if I had a 305.00. I used my E011.1 to call work to say I’d be late and hoped to avoid V62.1. He greeted me with a 784.42 indicating 300.4.

Last year I V49.89. The flights are arduous, subjected to E918 or being in V01.9 with a 780.92 E979.6 at E902.0. After landing I’m 780.79 due to V69.4 and 780.55, leading to excessive 786.09.

I was in 309.29. At least, thank to the ubiquity of E849.6, I didn’t have to suffer from 292.0.

If you think this makes for 315.00 and is a 729.1 to read, just wait for ICD 10! Ever see a V91.07XA?!

It was too hot. That, combined with lack of food and water, not to mention lack of sleep, is what led to my fainting. I admit it, I don’t exercise or eat right. I usually sleep well, but that night was different, thanks to interrupted sleep from my son’s crying all night. That morning I understandably drank one too many cups of coffee, leading my heart to skip a beat. During a hot shower I felt lightheaded. Stepping out my vision narrowed before I passed out. I awakened after my fall to the floor. I had a headache, as if I had a hangover. I grabbed my cellphone to call my work to say I’d be late and hoped I wouldn’t be in trouble with the boss. He greeted me with an edge to his voice, indicating he was wasn’t completely happy.

Last year I traveled to foreign countries. The flights are arduous, subjected to being squeezed in with other passengers, or being next to a crying, germy child at altitude. After landing I’m worn out due to lack of sleep and jet lag, leading to excessive yawning.

I was in culture shock. At least, thank to the ubiquity of vendors, I didn’t have to suffer from caffeine withdrawal.

If you think reading this is difficult and is a pain in the butt to read, just wait for ICD 10. Ever see a burn due to water-skis on fire?!

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Going Viral is Bad for Your Health

A few days ago CNN hosted the 2nd Republican presidential debate. Unfortunately, the topic of vaccines came up. Donald Trump had previously suggested that vaccines can cause autism. When asked about this he responded, “You take this little beautiful baby, and you pump — I mean, it looks just like it is meant for a horse, not for a child, and we had so many instances, people that work for me, just the other day, 2-years-old, beautiful child went to have the vaccine and came back and a week later got a tremendous fever, got very, very sick, now is autistic.”

He went on to say that he’s not against vaccines, but just thinks the same total dose should be given in smaller doses and spaced out more.

Donald Trump is not a doctor, so why is he giving medical advice? Republican presidential hopeful Dr. Ben Carson, a retired pediatric neurosurgeon, said, “We have extremely well-documented proof that there’s no autism association with vaccinations. But it is true that we are probably giving way too many in too short a period of time.” Although he at least discredited the theory that vaccines cause autism, he agreed with an alternative dosing schedule. Fellow debater Senator Rand Paul, who is also an ophthalmologist, said, “I’m all for vaccines, but I’m also for freedom. I’m also concerned with how they’re bunched up.”

The American Academy of Pediatrics put out a statement saying there is no alternative dosing regimen. Based on lots of scientific literature and much expert opinion, the current schedule was designed to optimize benefit versus risk. Delaying vaccinations increases the risk that children will catch the disease before they have been protected. It’s also psychologically more traumatic. Studies have shown that a child is just as traumatized if they get one shot or three shots at one visit, but 3 visits with a shot at each one is worse than one visit where they get 3 shots. Spacing out the vaccines also means more cost, and more exposure to sick kids each time they are brought for a vaccination.

So where did this idea of spacing out vaccines come from? Pediatrician Dr. Sears published “The Vaccine Book” in 2007 that proposed alternative vaccination schedules.  But that was just his opinion, and was not based on studies to show that it’s safe and effective.

The belief that vaccines can cause autism came from a study published in 1998, that has since been retracted because it was found to be based on fraudulent data. Some people still choose to believe it.

You might argue that spacing out the vaccines is better than nothing. That’s true, however that’s like saying that only wearing seat belts every other day is better than nothing. That’s true, but it’s still much better to use it the way you’re supposed to.

Republicans don’t have good record when it comes to vaccines. Four years ago Rep. Michele Bachmann (R-Minn.) attacked Texas Governor Rick Perry for mandating that young women get HPV (human papilloma virus) vaccine. He later backed down. That vaccine prevents women from getting cervical cancer.

I may not agree with politicians when it comes to issues regarding such things as  immigration, taxation, use of the military, domestic spying, or abortion, but those are legitimate areas for politicians to debate and legislate. They can even debate the wisdom of the Affordable Care Act (ObamaCare), but they should stay out of the science of medicine. That includes politicians who happen to be physicians, unless they are stating medical facts, rather than pandering to what their constituents want to hear.

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Medicare Audits – Or How I Spent Part of Labor Day Weekend

Copyright 2105 Daniel Ginsberg PhotographySome weekends I go to my office to try and catch up on paperwork. This Labor Day weekend I had to ‘labor’ away part of it to satisfy a Medicare requirement.

I received a fax from a medical supplier saying that Medicare had sent them an, “additional documentation request” for diabetic supplies for a patient of mine from June 2013. I didn’t see her on the date of service they listed, nor even see that I prescribed any diabetic testing supplies then, though it’s possible I filed out a faxed form and it wasn’t saved to her chart.

They requested that I include copies of the patient’s blood glucose testing logs. I do not routinely scan those into the chart, so I don’t know how that’s supposed to happen.

They also say to verify that the records contain the following other items, though it could be considered fraud to go back and add them now:

  • Patient’s Diagnosis and Prognosis
  • Patient’s Testing Frequency
  • Condition and Treatment History
  • Quantity and Day Supply Prescribed
  • Physical Limitations Due to Condition
  • A1c Lab Report
  • Insulin/Non-insulin
  • Insulin Injections/Pump
  • Medication lists

In addition, they want all documentation from 6 months before the service date up to the present day, and they want it, “ASAP.” That’s 2 years and 9 months of documentation, all for a few diabetic test strips I prescribed (which I don’t make any money from, for the record)!

What’s more, it says that we are not allowed to charge the supplier or the beneficiary (the patient) for providing this information.

That’s your government, hard at putting us primary care doctors to work.

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Asinine Associations

As I previously wrote, when physicians place orders, they have to associate diagnoses. This is becoming even more painful as we move towards ICD-10, of which I’ll have more to say later.

I’m sure this was an attempt by the government to save money, but in the vast majority of cases the ordering physician has no secondary gain, and they order the test because they think it’s the right thing to do. I can understand it for some expensive tests or procedures, but many are just plain obvious.

I think lawmakers should have a taste of their own medicine. When they need office supplies, they should have to give a reason. Here, I’ll help them out with a few items to help them understand how it works:

StaplesTo attach separate pieces of paper.

NotepadTo write down information.

PenTo apply in conjunction with a notepad to convey information.

ChairTo help counteract gravity to prevent leg and back pain and fatigue.

Laser Printer TonerTo print out things using a laser printer.

Light BulbTo counteract darkness.

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Sesame Chicken


I often suggest my patients use smart phone apps to help them with their diet, in particular Lose It! or MyFitnessPal. Both progams have the ability to scan a bar code of a food item, which will then show the amount of calories, protein, fat, carbohydrates, etc for a given portion size. Not having any food in my exam rooms, I grabbed the box of tissues to show how to scan the bar code. Lose It! identified it as Sesame Chicken!

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A High Tech Call Schedule


Typical of many physicians, I have to take turns being on call. This mostly involves taking calls in the evening, at night, and on weekends for my patients, or those in my call group. I belong in a group with 6 other internal medicine doctors. We no longer have to go to the hospital to admit patients, since that is now done by dedicated hospitalists, but may answer calls about patients in our practice that show up in the emergency room, or are in a nursing home and having issues, or have significantly abnormal laboratory results that come back after hours.

My group takes call a week at a time, and the schedule is made each December for the following year. Each person in the call group submits a list of days they do not want to be on call, and the person making the schedule does their best to accommodate everyone. If someone needed to make subsequent changes, they would need to check the schedule and try and find someone to switch, or others would take their call in the event of a personal or family emergency. The call schedule was 12 pages of a printed calendar with the call person written for each day.

Last year the person making our schedules retired and I took over the duty, with the agreement that the schedule would be computer based. I created a Google Calendar, for the call schedule. I assigned each person their own color and created the schedule, after working it out on paper first to make sure I accommodated preferences, made the schedule as fair as possible in terms of amount of call and holiday coverage, and trying to spread out call.


I sent out invitations through Google Calendar. Now everyone in the call group can see their schedule on their computer. They can also use an app on their phone, as shown below. If changes need to be made to the schedule they notify me or our office administrator to make changes to the calendar. Everyone in the group then automatically gets the updated version if they check their calendar.


Recently I added a new twist. Having purchased the Amazon Echo, I added my Google Calendar to the app. Now I can ask Alexa what’s on my schedule, and she will read who is on call!



Posted in Business of Medicine, Informatics | Tagged | 1 Comment

Medicare Payment Formula Finally Changed – Win or Loss?


Congress passed a  law in 1977 linking Medicare payments for physician services to growth in the economy.  Because it failed to take into account inflation and other factors, Congress has had to act 17 times to prevents cuts to physician pay under the sustainable growth rate (SGR) formula. This year physicians were set to get a 21% pay cut this year. This created a lot of stress and uncertainty for physicians, and caused some physicians to stop accepting Medicare patients.

The Senate recently voted to repeal this formula, 92 to 8. The bill was already approved by the House, and now President Obama has signed the bill.

That sounds like a great triumph for physicians. Although this may prompt some to pull out their imaginary violins in mock sympathy, I’m not so sure it will turn out to be such a great deal for physicians, which actually only consumes 12% of the Medicare budget.

The bill freezes the current rates, then increases them 0.5% a year from 2016 to 2019. For 2020 through 2025 there is no increase, and from 2026 onwards it increases by 0.75% per year. That is far below the current rate of inflation, and there is no provision if inflation gets worse than the currently low rate. That effectively means a real loss every year into the indefinite future.

There is a provision to transition payments to reward physicians for quality, rather than quantity. That is good in theory, but we’ll have to see how that works out in practice. Quality healthcare is very difficult to measure, and there is a risk that quality will be defined based on what’s easy to measure, and that will lead to physicians and other healthcare providers to concentrate on what they are rewarded to do, and not what may be in patients’ best interest. I hope I’m wrong.

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Healthy Kitchens, Healthy Lives



Dr. David Eisenberg with his son and daughter demonstrating healthy cooking.

I recently attended the 11th Healthy Kitchens, Healthy Lives Conference put on by the Harvard School of Public Health and the Culinary Institute of America. It was a literally delicious combination of lectures from physicians, dieticians,  chefs, and others.


Chef Adam Busby of the Culinary Institute of America

There were 411 people registered for the course, coming from 35 states, and internationally from 29 countries. Including spouses, faculty, chefs, and exhibitors, more than 550 people attended. For those registered, 59% were physicians, 11% nutritionists, 5% nurses & nurse practitioners, 5% masters of public health, and 20% others (chefs, psychologists, physical therapists, exercise trainers, physician assistants). The majority of physicians were internal medicine and family medicine, but also pediatrics, OB/GYN, sports medicine, psychiatry, anesthesiology, cardiology, endocrinology, and surgical specialties. A diverse group, indeed.

We had lectures from top notch physicians, dieticians, chefs, and others. Many were book authors. I already made a couple of recipes from Suvir Saran autographed book.


Dr. Eward Phillips talking about exercise.

They fed us well, with something like 350 different healthy dishes to try.


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We also had a hands on kitchen session, then ate our own cooking.


Chef Thomas Wong



Now the challenge is how to use all the information and get my patients to eat healthier. As a start, I’ve posted some healthy recipes on Pinterest.

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Patient Satisfaction / Physician Dissatisfaction

Have you received a survey after you visit your doctor? You may be surprised to learn that how you rate them may affect their pay, their mental health, and even possibly your health.

Surveys, as administered by Press Ganey, and the CG-CAHPS,  are questions regarding various aspects of the care patient’s receive. Although that may seem reasonable, besides potentially incentivizing bad medicine, it’s exaggerated because they only count “top box” scores. That means on a scale of 1 to 5, only the 5 scores count, so that getting a 4 is no different than getting a 1, and if the score is 0 to 10, then only a 9 or 10 count. The scores only count if you answer “Always,” except for the question, “Using any number from 0 to 10, where 0 is the worst provider possible and 10 is the best provider possible, what number would you use to rate this provider?.” In that case, only a 9 or 10 count.

I’m not sure how this rating system was developed, but I think it may have had roots in the hospitality business. A patient may stay with their doctor if they rate them as being good, as opposed to excellent, but if someone better comes along, they may change. So if if you want high customer loyalty, you want to aim for excellence. Thus from the point of view of the physician, or rather the point of view of the administrator who pays the physician, one should strive for the top box scores.

In practice it’s not so simple. Take the question, “In the last 12 months, when you phoned this provider’s office during regular office hours, how often did you get an answer to your medical question that same day?” The only one that counts is the answer “Always.” So imagine you call 5 minutes before close to ask if you need to get lab work done before your appointment next week. Chances are for such a non-urgent question, it won’t even get to the doctor to answer before the next day, assuming you didn’t call on a Friday, and the doctor is in the office that day. You be perfectly satisfied to get a call back the next day, but if you answered the question honestly, you’d mark “Usually,” which when scored, would be the same as if you marked “Never.”

Although customer satisfaction is important in the medical field, it’s not the only thing that counts. I’ve had patients leave my practice solely because I told them things they didn’t want to hear, such as they needed to stop smoking, cut back on alcohol, exercise more, and lose weight.  I try to do it compassionately and offer them help, but it doesn’t necessarily make patients want to give you a good score.

What’s makes the system worse, is that when comparing scores, it’s graded on a curve. By definition, no matter how good doctors are, there will always be some that are on the high end of the curve, and some on the low end. This in turn is used to save money by paying the people lower on the curve less.

Sochi TimesLook at the charts above. The one on the left represents 47 individuals who were rated on something, showing their percentile rank, ranging from zero to the 100th percentile. Clearly there is a wide range in how well they did.

What about the chart on the right? Those are the same individuals showing the time in seconds they spent completing the task. There is less than a one second difference between the top 12 people. There is less than a two second difference between the person at the 49th percentile, and the one at the 85th percentile. So it should be easy to move up the percentile ranking, shouldn’t it?

What do these graphs represent? The results of the 2014 Olympics Alpine Skiing Downhill Men’s Final in Sochi.

What’s the point? Percentile rankings are not a good measure of excellence when the differences are small. In the Olympics we care who is number one, but patients want excellent care, and don’t distinguish between different doctors or institutions if they need a magnifying glass to see the difference. We all have room to improve, but it’s demoralizing to be told one is in the 20th percentile. I’d much rather be told I was only 6 seconds behind the winner.

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January Resolutions

Ladybug_6D300This is the time of year people make New Year’s resolutions. Many goals get made repeatedly each year because it’s hard to sustain changes in habits to make progress in things like losing weight. People start off good, but a year is a long time.

If you are trying to lose weight, stop smoking, exercise regularly, or achieve some other goal that eludes you, try making a resolution to do those things for the month of January. It’s a lot easier to do something (or not do something) for a month, than to keep it up for 365 days.

At the end of the month the work you’ve done towards your goal may have almost turned it in to an ingrained habit, making it all the easier to make a resolution for February, an even shorter month.

With two months under your belt, you are well on your way. Happy New Year!

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