June is Men's Health Month, when we focus on prevention, detection, and treatment of disease in men and boys. As a cardiologist, it is tempting for me to use this platform to talk about heart disease. Instead, I have decided to push myself beyond that, connecting to my cardiology roots while shooting for some extra bonus points by mentioning coding and Clinical Documentation Improvement.
I saw a patient in the office for follow-up two weeks after an acute inferior myocardial infarction (MI) - commonly known as a heart attack -- caused by a right coronary artery occlusion (that would be ICD-10 code I2.11). Remember that the meaning of "initial" and "subsequent" for MIs has changed since ICD-9, where it referred to the episode of care.
However, under ICD-10, this office visit for the single MI within the previous four weeks did not get any special code modifier. As he was leaving, the patient asked me to check his PSA (the Prostate-Specific Antigen that helps detect and screen for prostate cancer). Apparently, his family doctor normally did this, but it hadn't been checked in a while.
He called a few weeks later to tell me that his insurance company refused to pay for the PSA check, as the test is not indicated in the context of a follow up visit after a heart attack. It would have been covered if I had documented our discussion and coded for an encounter for screening for prostate cancer (Z12.5). [See how I snuck in a mention of coding and Clinical Documentation Improvement?]
Well, not too long after that my friend Joe called. He was upset that his PSA test was high, and had increased since the previous test (this change is sometimes referred as the velocity of the PSA blood level). Fortunately, I enjoy acting as a "medical concierge," as I know many good doctors, many nice doctors, and a few who are both.
I referred Joe to a nice and good urologist, knowing that he was headed for a prostate biopsy. Joe called a few weeks later while I was eating dinner, anxious to share the news that the biopsy was done in the urologist's office, totally painless, and the pathology results were completely benign.
He went on to describe the biopsy procedure in a little more detail than I needed to hear while eating. Twelve prostate samples were taken (one at a time) using a spring-loaded needle device that was inserted through the rectum, along with an ultrasound probe to guide the biopsy location.
He said that the biopsy device sounded just like a staple gun, and he was not sure that he would ever be able to use a staple gun again. This is most unfortunate, as Joe does construction work. He also described his experience trying to tell his wife about the procedure, and how undignified the whole thing was.
She apparently replied "Yeah, tell me about it," no doubt thinking about her annual pelvic exam and Pap smear. [We'll have to save further discussion of that for next January which is Cervical Health Awareness Month.] Prostate cancer is the most common cancer in men in the United States, and the second most common cause of men's cancer deaths.
It may not cause any symptoms and unfortunately half the time it has already spread by the time the diagnosis comes around. Early detection is important, with the goal of detecting before it spreads and is potentially curable. Despite these facts, you don't hear much about prostate cancer in the lay press or media.
Until, of course, a celebrity is diagnosed with the disease. You should spend a few minutes doing an internet search using the search terms "prostate cancer" and "celebrity." You'll be amazed at the list, which includes:
- ACTORS: like Charlton Heston, Laurence Olivier, Robert DeNiro and Roger Moore;
- POLITICAL FIGURES: like Robert Dole, John Kerry, Rudy Giuliani and Colin Powell;
- ATHLETES: Stan Musial, Arnold Palmer, Ty Cobb, Joe Torre; and
- MUSICIANS: like Frank Zappa, Harry Belafonte, James Brown, and two of my personal favorites Dan Fogelberg and gentle soul Jesse Winchester.
The American Cancer Society recommends prostate screening for all men over age 50. Men at higher risk (for example, African-Americans, and those with a family history of prostate cancer) should be screened starting at age 45. Typically, screening is done during a rectal exam, checking the feel of the prostate with a gloved finger.
This may be augmented with a PSA blood test. Medicare and most insurance companies will reimburse for this procedure annually. So:
- Men who are reading this who fall into one of these categories -- make sure you get your annual screening, this year and every year.
- Providers -- be sure to do annual screening for the prostate health status of your eligible patients. Discuss this with your patient and document the need for the screening, and the date and results of the last screening if any.
- Coders -- be sure that the medical necessity is properly documented and coded. By the way, if a Digital Rectal Exam is performed as part of other Evaluation and Management services done on the same day, this gets bundled in rather than being coded separately.
- And, ladies, cut your man some slack. Give him a one-time pass to whine about the undignified and embarrassing examination of his private parts. Let him think that his is the only gender that has to suffer this indignity. You can always enlighten him tomorrow.
About the Author
Dr. Jonathan Elion, MD, FACC, is a practicing board-certified cardiologist in Providence, RI and an Associate Professor of Medicine at Brown University. With over 40 years of experience in computing and more than 25 years of experience in medical computing and information standards, Dr. Elion has committed his career to innovations in high value services and healthcare delivery to maximize efficiency and cost effectiveness.
Jon is the founder of ChartWise Medical Systems, Inc., a Rhode Island based company that recently introduced ChartWise 2.0. It is the first-to-market interactive software system designed to improve precision in quality clinical documentation and to support revenue assurance through its web-based, comprehensive built-in expertise, electronic queries and robust on-demand reporting.