Letters

Not-so incidental expenses

To the Editor:

I received a letter the other day from an insurance company informing me it would not pay for office urinalysis because its "medical staff" decided that under the company's reimbursement policy, the reagents, specimen cup, reporting form, gloves, hazardous-was te disposal and office personnel involved in this test were "incidental" and therefore worth nothing. If a dipstick urinalysis is incidental to an office visit, how about a hemoglobin, hematocrit -- or even a CBC? There is no end to this slippery slope.

More and more, we're seeing insurance companies and Medicare climbing into the driver's seat. For years they've felt they have the right to call the tune because they pay the piper. But, like the ill-fated council members of Hamelin, they now want to call the tune and not pay the piper. Allowing insurance companies or Medicare to decide what they'll pay and when they'll pay it is like asking someone who owes you money how much he or she feels like paying. Try getting insurance coverage without paying exactly what they charge.

Several years ago the major HMOs garnered enormous profits by drastically cutting back payments to physicians and hospitals for medical care. Then they invested large amounts in buying medical practices. Now they've been quietly backing out of those investments since they've discovered that dismal payments from medical insurers like themselves have made it nearly impossible to run profitable group medical practices. They've discovered that insurance companies and Medicare have all but ruined the practice of medicine.

The revolt is long overdue. It's time for us to take back our health care system.

Karl Sandberg, MD
Ola, Ark.

Commendable advice

To the Editor:

Kent Moore, author of "ICD-9 Coding: Every Digit Counts" [October 2000, page 16], must be commended for providing a quick refresher on ICD-9 coding and urging physicians to provide fourth- and fifth-digit codes when required.

I would like to add that reimbursement is just one reason for endorsing complete coding. Another equally important reason is the ability to use patient diagnostic records for research purposes -- research that may form the backbone of preventive measures for certain health conditions. For example, one cannot accomplish a retrospective study of burns by degree of burn using hospital records unless discharge ICD-9 codes are specified to the fourth and fifth digits. The fourth digit describes the percentage of body surface area affected and the fifth digit describes the percentage of body surface with a third-degree or full skin thickness burn.

Indeed, as Moore pointed out, coding should be done with as much specificity as possible.

Samuel N. Forjuoh, MD, DrPH
Temple, Texas

Kindness pays

To the Editor:

"Documenting High-Risk Cases to Avoid Malpractice Liability" [October 2000, page 33] discussed the diseases commonly associated with malpractice litigation and highlighted five clinical situations where the risk associated with misdiagnosis is high. It was predictable that myocardial infarction would top the list and that three common cancers -- colon, lung and breast -- would be cited.

I'll admit to being surprised to find acute appendicitis on the list, but this condition does have certain characteristics that can make it easy to miss. Simply put, the clinical picture may unfold gradually over hours to days, so establishing the diagnosis may require multiple examinations. A patient who has only vague symptoms and a soft, mildly tender abdomen when first seen may develop the full-blown picture later. It follows that the patient (or the parents, if the patient is a child) should receive specific instructions about what to do if the pain doesn't go away in a few hours. This may require a return visit, a phone call to the on-call doctor or a trip to the emergency department, depending on the circumstances.

It is important to be aware of these clinical situations, but remember too that a primary determinant of malpractice suits is anger. Patients occasionally sue physicians they like and respect, but they're much more likely to take action against those they perceive as uncaring or unwilling to listen. In the immortal words of the apocryphal sage S.K. Lapius, "Rude doctors are sued doctors."

Robert D. Gillette, MD
Poland, Ohio

Corrections

We failed to credit the artist who illustrated our January cover. Our apologies to Lael Henderson.

"Electronic Medical Records: The FPM Vendor Survey" [January 2001, page 45] stated that Glaxo Wellcome Inc. supports HealthMatics electronic medical records software. In fact, Glaxo no longer supports the product.

Copyright © 2001 by the American Academy of Family Physicians.
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