Coding sphinxes rain down curses

"Dr. Zahi Hawass, we are so thrilled that, as Secretary-General of the Supreme Council of Antiquities of Egypt, you have chosen our ultrahigh-tech CT scanner to look inside King Tut for new clues. Our CT tech Dave, just back from applications training, will be scanning Tut as our first 'patient.'"

"Good morning, Dr. Hawass. I just need to connect these electrodes to you."

"No, no. I am not the patient, King Tutankhamun is."

"Yes, I know, sir. But this machine is the first to address federal regulations that all scans meet Medicare-approved indications."

"If you say so, but it seems a bit odd."

"How old is the patient?"

"3349 years."

"Weight?"

"50 kg."

"Reason for the study?"

"R/O pathology . . . ooh! I think I just got a little shock."

"Yes, sir. We cannot use R/O. We have to have a specific reimbursable indication like chest pain, trauma, cough."

"Well, he is dead."

"Sorry, but 'dead' is not reimbursable."

"Then try chest pain . . . ooh! I definitely felt a shock that time."

"Yes, sir. The CT console tells me you're lying. We have to have a truthful indication."

"I don't know why he died! That's why we're doing the CT."

"Still, I need a reason."

"Try trauma then. Yikes! I got shocked again."

"Any untruthful statement will elicit a shock to discourage additional lies. All part of our government's improved healthcare system. Next year's model will have waterboarding capabilities."

"Unbelievable! These shocks are giving me a horrible headache."

"Headache, and you appear to be telling the truth. We could do a head CT on you if you want."

I recently had my own headache trying to get my mummy imaged at a local hospital. I was just about to leave on vacation for Egypt, and my mother took a turn for the worse and had to be admitted to a nursing home. I was frantically trying to get everything taken care of, and one of the requirements of the home was proof that she was free of any evidence of tuberculosis, either a negative skin test or a negative chest x-ray. There was no time to get a skin test, so I took her to our local hospital for a chest x-ray.

I got her registered, and then they asked the reason for the chest x-ray. I said R/O TB. They looked at me like I was the former governor of New York asking for a date.

"I'm sorry doctor, but as of Jan. 1, we are no longer allowed to use R/O. We need a valid symptom or abnormal lab value. Does she have a cough, fever, chest pain, wheezing, shortness of breath, hemoptysis, or elevated white blood cell count?"

"No. No. No. No. No. No and no."

I eventually ended up with about half a dozen people trying to help me get around this obstacle. Multiple phone calls were made, x-ray techs consulted, a supervisor at a sister hospital called, a coding specialist contacted. The FBI, CIA, and NSA were consulted, to no avail. R/O TB was not a valid reason, so no chest x-ray.

Okay, I would just pay cash for the study myself, since I was desperate, with a looming airplane departure. Sorry, still no go, they said. The policy was the policy whether it was insurance or self-pay. Arrgh!

Now, these people were not being difficult-far from it. They were sincerely trying to help me with suggestions.

"Mightn't your mother have had a slight cough? A brief moment catching her breath? A slight twinge in her chest?" I could see we were about to slide down the slippery slope, but I held firm.

"No, she did not have any of these symptoms."

They looked crushed, but I would not give in.

Unfortunately, the nursing home couldn't put their other patients at risk without some assurance that my mother did not have TB, while the hospital could not violate its new policy by doing a study without a valid indication code. I was stuck between a rock and a hard place, and the clock was ticking down.

Wonderful Egypt trip versus no wonderful Egypt trip. Tell the truth versus tell a little white lie. Clear conscience versus Medicare fraud.

Hmmmm. Which to choose?

What would Jesus do? That didn't work. What would a politician do? Yes! I fudged. The final history I gave was: TB? Smiles and congratulations followed. Crisis averted. Tuberculosis was a valid indication for a chest x-ray, and the program doesn't take punctuation into account. Got the chest x-ray, got mom into the nursing home, and got myself off to the airport-stressed out and worried that the Federales would be waiting for me on the tarmac on my return home-but on the plane nonetheless.

I still routinely get requests that say R/O pathology, so I appreciate that hospitals are actually demanding some relevant clinical history, especially since studies show that it clearly improves the interpretation a radiologist provides. There are still doctors, however, who say they don't want to give the history for fear of "biasing" us, which is like asking for directions but not saying where you want to go! Many groups actually rely on their coding and billing staff to try to come up with a valid billing code by reading the report or chart, which is unacceptable.

I fully support the need for proper history, but now I have a slightly more nuanced appreciation of what clinicians have to deal with when they are just trying to do the best for their patients. Some may stretch the truth to get their patients what they need when faced with an inflexible system. I've become more sympathetic, having gone through it myself.

My mummy is out of the nursing home, safe and sound again, but I am still watching my back, worried about extraordinary rendition from the Medicare police for my tiny fraud.

Dr. Trefelner is a radiologist and cofounder of NightShift Radiology. He invites comments by e-mail at ericxray@pacbell.net or fax at 650/728-5099.