By HANS DUVEFELT, MD
The chest CT report was a bit worrisome. Henry had “pleural based masses” that had grown since his previous scan, which had been ordered by another doctor for unrelated reasons. But as Henry’s PCP, it had become my job to follow up on an emergency room doctor’s incidental finding. The radiologist recommended a PET scan to see if there was increased metabolic activity, which would mean the spots were likely cancerous.
So the head of radiology says this is needed. But I am the treating physician, so I have to put the order in. In my clunky EMR I search for an appropriate diagnostic code in situations like this. This software (Greenway) is not like Google; if you don’t search for exactly what the bureaucratic term is, but use clinical terms instead, it doesn’t suggest alternatives (unrelated everyday example – what a doctor calls a laceration is “open wound” in insurance speak but the computer doesn’t know they’re the same thing).
So here I am, trying to find the appropriate ICD-10 code to buy Henry a PET scan. Why can’t I find the diagnosis code I used to get the recent CT order in when I placed it, months ago? I cruise down the list of diagnoses in his EMR “chart”. There, I find every diagnosis that was ever entered. They are not listed alphabetically or chronologically. The list appears totally random, although perhaps the list is organized alphanumerically by ICD-10, although they are not not displayed in my search box, but that wouldn’t do me any good anyway since I don’t have more than five ICD-10 codes memorized.
Patients are waiting, I’m behind, the usual time pressure in healthcare.
Can’t find a previously used diagnosis. Search for “nonspecific finding on chest X-ray” and multiple variations thereof.
I see R93.89 – “abnormal finding on diagnostic imaging of other body structures”. Close enough, use it, type in exactly what the chief of radiology had said in his report. Move on. Next patient.
Several days later I get a printout of that order in my inbox with a memo that the diagnosis doesn’t justify payment for a PET scan. Attached to that is a multi page list of diagnoses that would work.
Frustrated, I go through the list. It’s another day, other patients are waiting. Eventually I come across R91.8 “other nonspecific finding of lung field” – not exactly pleura, but what the heck, close enough, let’s use that one.
Why is this – me hurriedly choosing the next best thing on a multipage printout, while my other patients are waiting – any more practical, accurate or fraud proof than having me describe in appropriate CLINICAL language what the patient needs and letting SOMEONE ELSE look for the darn code?
Here I am, trying to order what a radiologist told me to order, without having the tools to do it.
Next thing you know, Henry’s insurance will probably have some third party radiologist deny coverage because he disagrees with my radiologist, and I’ll be stuck in the middle…
Not quite what I thought I’d be doing. Who works for whom in healthcare?
Hans Duvefelt is a Swedish-born rural Family Physician in Maine. This post originally appeared on his blog, A Country Doctor Writes, here.
That’s the old way…just like verbal orders largely went away, and just like you can’t write QS (Quantum Sufficit) on electronic prescriptions and have the pharmacist figure out how many pills in your prednisone taper. The brave new world is making us do our own ordering. Sorry to inform you the workflow you’re enjoying is going away – prepare to pick your own codes.
Here’s the system we’ve set up in our office:
Doc writes “PET chest” on piece of paper
Trained staff does the rest
Doc takes a pee-pee break or goes out for a smoke.