A doctor’s experience with ICD-10: Day 1

shutterstock_153408407 (2)A doctor’s experience with ICD-10 on day 1 from a Sermo member.

“I’m sorry, Dr. Kellycola, you can’t order an echocardiogram for your patient. You have to give me the ICD-10 code first!”  WHAT? You’re the coder! Why do I have to provide you the ICD-10 code?!?!” “Sorry, Dr.; no code, no echo!”  I was astounded.

ICD-10? No worries! After all, I’m an employed physician. My employer has well trained coders. I order very few tests.  ICD-10 will be a piece of cake. RIGHT.

My day 1 troubles began at 0730 on Wednesday, October 1, when a 77 year old man with “painless weight loss” presented for preop evaluation for EGD and colonoscopy. Normally, I wouldn’t even consider ordering an echocardiogram for a patient having an EGD and colonoscopy, but this is one sick man. The patient explains “my aortic valve is closing up on me, my last echo was 3 years ago, my doctor says my heart is so bad there is nothing else they can do, and I coded during an EGD at this hospital, in April of this year!” THAT brought out the red flags!

I started researching. The paper anesthesia record from April reveals: 1” nitro paste preop, 100 micrograms of fentanyl IV and 2 mg of versed IV. That’s it. NO other meds.  EGD done. Patient went into PEA. Intubated. Resuscitated. Hmm. Can’t get old echo report right now. He’s NYHA Stage III and getting worse.

OK, I think the man needs a “cancellectomy,” but given the current scenario—if the patient is breathing, you really have to defend NOT doing the case, I decided an echo would help with risk stratification. Except, I couldn’t order the echo!

I tried the old ways that had always worked; give them the reason the patient needs the test (CAD, aortic stenosis) and it will be approved. No. “I need the code, doctor.” Heck, I don’t know the code!  I tried persuasion. No. I tried appeals to help a sick, elderly man and his elderly wife, who has Alzheimers. “What’s the code?”  Sigh.

After more than an hour of my time, a frustrated patient and his wife, time spent NOT seeing other patients, a CRNA told me she had heard that the hospital opened up their “ICD-10 hotline,” and I found the codes for an echocardiogram.

Here were some of the choices:  TTE vs TEE I could understand, but: left or right heart?  Seriously? Am I missing something here? Who orders or needs “Just” the right or left heart on an echocardiogram? Can you DO, just the left or right with an echo? With or without contrast?  The choices went on and on, and FINALLY, I was able to figure out the needed code, so the poor patient could get an echo.

Oh—echo shows aortic stenosis 0.6 cm2. Also finally obtained old echo and old heart cath from three years ago.  Aortic valve then was 0.7 cm2. Last heart cath was 3 years ago, and lots of in-stent occlusion, RCA completely occluded. Discussed with patient and surgeon. If patient coded with EGD, what is endpoint if you do find a colon lesion causing weight loss?  Patient decided on Cancellectomy. Surgeon agreed.