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Avoiding the Shoals of Contracts and Codes

complain last week because I billed for a physical and it wasn't covered. But she said her insurance told her they would cover a Pap."

Karen stepped up to the plate this time. "A Pap smear is covered under the state Women's Health Initiative."

Linda added, "And a lot of HMOs will pay for preventative care." HMO, health maintenance organization, I thought to myself, trying to take comfort from recognizing another acronym.

"A V70.0 is a physical," Linda went on. "Are you doing the whole thing? Listening to her heart and lungs? Past history, family history? Of course, if she's a return, it's only an update." I was struck that my patient had been reduced to "a return," just as I'd become "a primary care." We all get abbreviated to our billing functions, I thought.

"Of course I am," I answered. "Most of the time in someone young those are pretty simple, but they could turn up something important."

"If you are just doing a Pap you could code a V72.3—gynecological exam with routine cervical Pap."

"So I should code that instead of a V70.0, physical exam?"

"No, V70.0 is better. A V72.3 assumes you're just swabbing her cervix and not doing anything else. There's less compensation." I'd noticed that the word "compensation" was used instead of "payment," as though money changed hands as a kind of apology for our inconvenience.

"But will the insurance pay for a V70.0? Is that covered under the . . ." I tried to recall the name of the program. ". . . the Women's Health Initiative?"

"Not necessarily," Linda responded. "Some insurances cover it, some don't."

"Which ones?"

"It's always changing."

One day we had a long meet- ing about the expense of transcriptions and were told to cut the length of our dictations. The next day, we were told if
we didn't detail every nuance
of each patient conversation, we were liable to get sued. "This is crazy!" I said.

"So if I code a V72.3, I don't get paid for the work I did. But if I code a V70.0, I do get paid but she might get the bill."

Karen nodded.

"Or she might not," I added, "and there's no way for me to know?"

She nodded again.

"And we're surprised that this confuses people?"

There was a long silence. Finally I looked down at my watch. "I think it's time for me to get back to the easy part of my job," I said, as gently as I could, "seeing patients."

Luckily I enjoy seeing patients, and by the end of the day I was cheery again and ready to tackle the coding labyrinth once more. Just before I left for home, I got a text message from a friend who was also just starting practice.

"Did you know there's an ICD-9 code for legal execution?"

"Really?" I wrote back.

"E978 covers lethal injection, death by firing squad, electrocution, beheading, and other means not otherwise specified."

"Thanks," I wrote back. "I'm glad to know how to code what I want to do to the person who designed this system."

As a new doctor at my clinic, I was a magnet for advice. Physicians I'd never met came up to me to offer gems and pearls of wisdom—things, they said, they wished they'd known when they were starting out. They meant well, all of them, but as a cumulative mass the advice was overwhelming.

"Don't give anyone narcotics," one colleague told me. "There will be people in your office acting out the death scene

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