I hate medicare

-fancy-shoes-

I have a clinic patient who had a stroke years ago - it left them with a little bit of right sided weakness, but otherwise they are pretty functional. They came to me a few weeks ago as a new patient, their son at their side, for a general check-up. The only medical issues that they reported to me was hypertension and dementia; they were told a while back that they had Alzheimer's, and now were on Donepezil, an Alzheimer's medication. As I spoke with my patient and their son about the dementia, they told me it was mild. My patient was still living on their own, and their son thought this was not a problem, as he and his siblings would come and help pay bills, clean up and shop as needed; overall though, he reported, my patient was pretty self-sufficient. Sounded like pretty mild dementia to me. They'd had a recent CT from the doctor's office they'd switched from, and it showed that little areas of micro-infarcts; these are little areas in the brain that have been left without oxygen for enough time that the brain cells were damaged. As we continued talking, the son told me that his parent's slow decline was not happening gradually, but instead was happening in a step-wise fashion, and every few months they would all of a sudden have a bit of a worsened memory. This did not sound like Alzheimer's, it sounded like vascular dementia.

Vascular dementia is a type of dementia that is caused by, as their CT showed, little micro-infarcts in the brain. This can be caused by hypertension leading to tiny little bleeds, ischemia from a lack of blood flow (often due to narrowing of arteries or little clots.) In comparison, Alzheimer's is due to 'plaques' of random, mis-folded proteins that accumulate in the brain, disrupting the flow between neurons. I decided to do a work-up on my patient....

I wanted to order an echocardiogram (where we ultrasound the heart so they can get a good look at the valves, the chambers, the wall-motion, etc), a carotid ultrasound (where we look at the vessels in the neck to see if there is any narrowing that could potentially cause a stroke), an EKG (where we look at the electrical activity of the heart to make sure there is no abnormal rhythms that could be causing clots to form), and some blood tests to check cholesterol levels. The echo and EKG were easy to order, because the patient has hypertension, but the carotid study posed me more problems....

Now as I have previously ranted, the ICD-9 is the master and controller of all that is done in the office - if you want something done, you have to code it properly, or it will not be approved, or paid for, by insurance...Medicare is the biggest pain in my rear when it comes to making sure I am coding things absolutely perfectly in the ridonculous world that is Medicare's justification system. Unfortunately (and ridiculously), there is no code for 'History of stroke.' There are 'family history of stroke,' 'acute stroke,' 'known cerebrovascular disease' codes, but nothing that you might type in to order a SCREENING carotid ultrasound. I did not know what kind of dementia my patient has, so I couldn't code that it WAS due to anything in the carotids. In all honesty, I didn't even think that there was necessarily anything going on in the carotids (the micro-infarcts were, in my mind, more likely due to  hypertension that I was pretty sure wasn't all that well controlled - their BP in my office was 150/96, but that's not the point.) I had no documented screening carotid ultrasound in this 79 year old patient, and I felt that they needed one. So I ordered it under 'Dementia, unspecified,' thinking that this was an okay code - the patient has dementia, I'm not sure why. It is therefore unspecified.

Well, as it turns out, Medicare would not approve this. I got a message from the clinic saying that I had to call the scheduling office to come up with a new code. When I called the lady, she read off all of the codes that would work - among others that didn't apply to this patient.....


'Occlusion and stenosis of pre-cerebral arteries' (pre-cerebral, as in the carotids) - I wouldn't know this without an ultrasound or other study, now would I?

'Transient ischemic attack': they had not had one of these, so I can't just go about lying

'Acute cerebrovascular disease': nope...nothing acute going on here

'Occlusion of cerebral arteries': couldn't know this one either without a MUCH more expensive study, that I'm sure medicare would find some way out of paying.

So all I could code for this SCREENING test, were codes that were applicable to conditions that could have been caught by screening. Are you kidding me? Medicare sucks! I was on the phone with the scheduling lady for a good 20 minutes trying to come up with a code, and in the end, I just diagnosed the patient with 'Vascular Dementia' to get the test.

Medicare is supposed to be in place to help people. What is the point of a screening test if you have to have a stroke in order to have the test that can help prevent a stroke? Who come's up with these crap rules? I'm willing to bet that they aren't doctors, and their only worries are the money that goes into, and comes out of this system. I don't hope bad things upon people at all, but I feel like it will take every person in the upper-levels of Medicare to have a family member who gets screwed by Medicare, in order to change the stupid rules that are in place preventing people from getting the full level of care that they need, and deserve! I will definitely say that there is a lot of money that is wasted in the healthcare system, but I do not feel like this is any reason to hold back care from those people who are elderly/disabled/whatever and actually NEED the help from the government. It's ridiculous. So ridiculous in fact, that I plan a much more detailed rant into this 'secretly socialized' healthcare system that the US has....you heard me - I said the s word:

Socialized 

Eek!!! Stay tuned...