Tuesday, December 17, 2013

Can't win for losing

The Washington Post recently decided to demonize doctors, with a headline trumpeting, "An effective eye drug is available for $50, but many doctors choose a $2000 alternative."  The article tells the story of a miracle drug treatment for wet macular degeneration, which is one of the leading causes of blindness.  Avastin was approved in 2004 for treatment of colon cancer.  It targets a protein called VGEF, thereby decreasing harmful blood vessel growth in cancer.  This same protein is linked to wet macular degeneration.  The company that makes Avastin, Genentech, has created a slightly different molecule and development process to make Lucentis, which is FDA approved to treat macular degeneration.  For all intents and purposes, the drugs are the same.  Both target VGEF.  Both are effective for macular degeneration, according to several independent trials.  However, Genentech has only sought FDA approval for Lucentis to treat MD.  It does not produce Avastin in the proper size to treat MD.

Despite this, many ophthalmologists still use Avastin to treat MD.  They have to have a compounding pharmacy separate it out into the proper dose, which does introduce a risk of contamination, though the risk is slight.  However, using Avastin this way is certainly considered off-label, meaning using a medication in a way that is not FDA approved.

The newspaper clearly implies that doctors should use Avastin, and that there is no good reason not to. It implies that doctors who chose not to take the risk of using an unapproved drug are greedy, stating that the medicare reimbursement of 6% of the cost of the drug (a whopping $120) is driving their decision.

And yet, just a few months ago, The Washington Post published this article.  It decries the lack of oversight of pharmaceutical drug use in the elderly, specifically targeting the off-label use of drugs in Alzheimer's patients.

So, which is it, Washington Post?  Am I a saint or a sinner?  Is off-label use good or bad?  Or maybe, just maybe, doctors are using their clinical judgment in individual situations to guide their decisions.

Nah.

h/t to Overlawyered.com


Sunday, December 15, 2013

ICD-10 Crazy Codes

Medical coding.  It's an entirely separate language that distills all medical problems down to a "code."  Currently, ICD-9 is in use.  Every time you receive medical care, your diagnosis is translated to a code which is then used for billing purposes, among other things.   Your hypertension and high cholesterol? 401.9 and 272.4.  Your hypothyroidism? 244.9.

And so on.

ICD-10 is going into effect next year.  It will increase the number of possible codes from 17,000 to 141,000.  No potential for confusion or complications there.

Now, has medical practice become so much more complicated over the past 30 years that there are now 124,000 new diagnoses?  Of course not.  ICD-10 is just more specific than ICD-9.  Much more specific.

For example, if you were to present to your doctor now after getting bit by, say, a squirrel, the code would be E906.3 (bite of an animal other than an arthropod).  But under ICD-10, your doctor can actually code that it was a W53.21XD (bitten by squirrel) to make sure that it is not confused with a W55.42XD (bitten by pig).

Or, after that ill-conceived ocean swim, your doctor can bill appropriately for W56.01XD (bitten by dolphin) vs W56.11XD (bitten by sea lion) vs. W56.21XD (bitten by orca).

Do you see the importance of these distinctions??

There are other codes that I'm sure are crucial.  V9733XD (sucked into jet engine, subsequent encounter).  Got that?  Subsequent encounter.  They made a code to cover someone who got sucked into a jet engine, not once, but twice.




NO CAPES!!!

For those of you that worry about worst-case scenarios, there are also codes for you.  For example- T71224A (asphyxiation from being trapped in a car trunk).  This is to be distinguished from T71234A (asphyxiation from being trapped in a discarded refrigerator).  There are also codes to clarify if the fridge asphyxiation was accidental, assault, attempted suicide, or "undetermined."  If you're really unlucky, you might have to use V9020xA (drowning or submersion due to falling or jumping from a burning merchant ship- initial encounter).

By the way, I apologize for any typos.  I have a big bandage on my index finger, having done a W920xxA this morning (contact with powered kitchen appliance).


Actually, there's one ICD-10 code that probably covers this whole coding thing quite nicely- K62.89 (pain, anus).

Wednesday, December 4, 2013

If you give a patient a chest x-ray...

It's probably the rare parent these days who hasn't read If You Give A Mouse A Cookie, an adorable book by Laura Numeroff.  In it, a little boy gives a cute mouse in overalls a cookie.  This one little act sets off an exhausting chain of events that eventually comes full circle.



I was recently reviewing old records on a new patient.  I noticed that he had had an awful lot of tests over the previous couple of years, which struck me as odd, given that he was a pretty healthy person. Looking a little further, it seemed that a cascade of events had been set in motion that had started with one innocent little test- which was not even indicated.

This patient was a former smoker, having quit many years ago.  His previous doctor ordered a chest x-ray to screen for cancer.  This was unnecessary in  the absence of symptoms as it's a category D recommendation by the USPSTF.  Nevertheless, the doctor ordered it and the patient had it done.

And, with apologies to Laura Numeroff:

If You Give a Patient A Chest X-Ray

If you give a patient a chest x-ray, the radiologist will see some tiny nodules.
The radiologist will call you and recommend a chest CT.
When he gets the chest CT, which is otherwise normal, the radiologist will note some calcifications in his aorta.  This will make you nervous, and you will refer him to a cardiologist.
Because this is a cardiologist, in addition to ordering an aortic ultrasound, he will also order a stress test, echocardiogram and carotid ultrasound.
All of those studies will be normal, but the ultrasound tech will notice a thyroid abnormality.  This will cause you to send the patient for an endocrinology consult.
The endocrinologist will redo the ultrasound.  Then he'll order a thyroid uptake scan.  This will show an active adenoma, which is benign, but he'll recommend follow up ultrasounds every six months after that.  He also notices that the patient is slightly hypothyroid, and starts him on levothyroxine.
The medication elevates the patient's blood pressure, so you start him on an ACE inhibitor.
The patient comes back to you two months later with an ACE inhibitor-induced cough.
And if you see a patient with a cough...you're probably going to want another chest x-ray.