PRACTICE DIARY

Chapter 41

 


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Fam Pract Manag. 2003 Jan;10(1):69.

Another panic attack

They’re ba-a-a-ck! A year after my electronic claims clearinghouse told me they were shutting down my platform because it wasn’t HIPAA compliant and making me move to a different platform, they recently sent me a letter stating that the second platform wasn’t HIPAA compliant either and I’d have to change platforms yet again. The first time, they said I couldn’t switch platforms without upgrading my hardware and software. I proved them wrong. This time, I knew they were right. But I couldn’t decide whether the whole thing was just a ploy to squeeze more money out of me (since my clearing-house owns my software company) or whether there were truly insurmountable HIPAA incompatibilities in my old program.

I must confess that I take some pride in running my office on a 486 computer under a Windows 3.11 operating system with software for which my vendor no longer offers technical support. It’s been bulletproof, and I would rather fight than switch. So I pondered what else I could do but capitulate. And then I had an inspiration: Don’t change your software, change your clearinghouse! An Internet search for “medical electronic billing” yielded several leads. One proved to be just what the doctor ordered.

The folks at the new clearinghouse explained that there are two current electronic billing formats (NSF and print image) and that, down the road, there will be a HIPAA-required ANSI format. I currently sent my claims in NSF, they said, but since that was a proprietary format that could be changed by the vendor, I should try sending my claims as a print image file. This meant that, instead of printing my insurance claims to paper, I should print them to a file and send it to the new clearinghouse as an e-mail attachment. I had never heard of printing a claim to a file before, but was delighted to discover this feature in my “outdated” software. A few days later, Steve from technical support called to say it had worked!

I was relieved not be a hostage to my clearinghouse and vendor any-more. A feeling of empowerment wafted over me. “Life is good again,” I told my office manager.

Horses vs. zebras III

Virginia, a bright, sensitive and perceptive patient, appeared in my office with a new complaint. It wasn’t as though she didn’t have enough problems already – chronic atrial fibrillation, recalcitrant hypertension, type 2 diabetes, obesity and a history of congestive heart failure. Now she noticed her belly had swollen markedly during the past two weeks. It was, in fact, tympanic. “Virginia,” I suggested, “let’s get an abdominal ultrasound and find out what this is.”

The radiology report read “massive ascites.” Remarkably, everything else was normal. It was puzzling. The differential diagnosis for ascites included cancer and liver disease, but Virginia didn’t drink, had normal liver function and had had a total abdominal hysterectomy years before. The paracentesis fluid didn’t help either; it was something in between an exudate and a transudate, and her cytology, gram stain and culture were all negative. A CT of the abdomen and pelvis corroborated the ascites but otherwise didn’t tell us anything more than the ultrasound did. Neither did an echocardiogram. It was a fascinoma.

Virginia, however, was more terrified than fascinated, especially when the four liters we had taken off her re-accumulated within a week. I set her up to see our visiting gastroenterologist and did some preliminary blood work. The lab called me with panic values several hours later: potassium 7.1, creatinine 4.3. Damn CT contrast, I thought.

“Pat,” I asked my GI colleague, “would you mind putting Virginia in the ICU after you see her?”

Kayexalate, insulin and bicarbonate failed to bring down Virginia’s potassium appreciably, so I transferred her to a center where she could be dialyzed, see specialists and get diagnosed. A week later, her renal function and electrolytes had stabilized, but they still had no idea why she had ascites. A CA-125, the tumor marker for ovarian cancer, had come back over 10 times the upper limit of normal. So, for want of a better procedure, a laparoscopy was performed. The surgeon called it: cirrhosis.

“Isn’t that a histologic diagnosis?” I questioned.

“Not when her liver looks like her brain,” he said.

Her gastroenterologist pieced it together as long-standing non-alcoholic steatohepatitis eventually leading to fibrosis.

“I hate those diseases that just sneak up and bite you with no warning,” I told Virginia after she came home from the hospital.

“Well, I received marvelous care,” she said, “and liked all my doctors, except for the floorwalker. Are you old enough to remember what a floorwalker was?”

I shrugged, so she told me. “He was usually an older man, dressed to the nines, who strutted around the floors of a department store like a peacock, looking self-important. I had a doctor who was just like that, except he did it in the ICU. He was a pompous ass.”

Although Virginia was cirrhotic, I was much relieved to discover she was not yet encephalopathic. Not by a long shot.

Dr. Brown, a solo family physician living in Mendocino, Calif., is a contributing editor to Family Practice Management. These excerpts from his journal illustrate the many characters, stories and lessons family practice has to offer. No real patient names have been used.

Conflicts of interest: none reported.

Send comments to fpmedit@aafp.org.


 

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