Cracking the Medical Billing Code

First, I better own up to that being a very misleading headline. I am far from cracking the code (and I used to write documentation for medical billing software!), but I did notice something that didn’t add up when I had a mammogram a couple of weeks ago.

I mentioned in a recent post that when I went in for my second annual postmastectomy screening, the tech told me they needed to code it as diagnostic because of my implant. In that post, I wondered whether the diagnostic mammogram would be more expensive.

I found out it was not; however, the full covered cost was applied to my deductible, leaving me responsible for $145. I asked my insurance provider if the full cost of the routine screening also would have been applied to my deductible. The phone rep said I would only have been responsible for a 10 percent copay, or roughly $14. So I called the medical center billing department and asked them to go back and question the diagnostic code.

Implant or no implant, the reason for my visit was my routine annual screening. I don’t know if they’re using this coding for anyone with implants or if it was just me, but I feel like I landed in the middle of a Kafka novel. If I don’t get a satisfactory explanation, I will argue this one until the cows come home.

The funny thing is I went through $83,000 worth of demolition and reconstruction and never ran into anything this goofy until now.

I mentioned this was my second annual postmastectomy mammogram. You may be wondering whether something’s changed since the first one, and I wish I could tell you. I think I was just so relieved the results were normal that I didn’t pay attention. It’s quite possible I paid a $145 stupidity tax.

Don’t be like me. Whether it’s your breast cancer, your husband’s gallbladder or your child’s asthma, pay attention to those bills. If they don’t make sense, get someone on the phone and make them explain it.

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New Studies Offer Hope to Women With Early, Late Stage Breast Cancers

Every week seems to bring something new on the breast cancer research front, and this past week was no exception. Two new studies were announced on Thursday–one affecting older women with early-stage cancer and one affecting women with advanced cancers.

The first study discovered that women over age 70 may not need radiation for early-stage breast cancer. The study, conducted by the Avon Foundation Comprehensive Breast Evaluation Center at Massachusetts General Hospital, reported that women in this age group who are treated with lumpectomies and Tamoxifen do just as well as women who also undergo radiation. While the recurrence of breast cancer is slightly higher in the Tamoxifen-only group, the likelihood of dying from breast cancer is not increased. This is good news for anyone in that age group who wonders whether daily radiation for six weeks is worth it, and for those  who have already opted to forego it.

The other study, conducted by researchers at the biotech/pharmaceutical company Roche, combines two experimental antibody drugs. It’s being used on women with advanced breast cancer tumors that generate a protein called HER2. The women had previously been treated with other drugs. In the small, early-stage (phase Ib/II) trial, the drug combination shrank tumors in 40 percent of the women studied. The drugs are T-DM1 and pertuzumab. The Reuters report says a phase III study should be released in 2012.

Both studies will be presented at the American Society of Clinical Oncology meeting June 4-8 in Chicago.

It practically takes a scorecard to keep up with all these developments–the drug names and interactions alone can get a bit dense–but that’s a good thing. (As are the doctors who help guide us through this informational maze–God bless them all.) Treatments are getting better and breast cancer is being caught earlier than ever, but it’s still killing too many women. It’s nice to know that researchers aren’t sitting still.

The Letter

I had my second postmastectomy mammogram on Wednesday. Mammograms have never scared me and they still don’t. I wondered if they might once I had breast cancer, but there’s comfort in routine. Same room, same tech, same digital mammogram equipment with the oddly beautiful name Selenia.

One thing has changed. Because of the mastectomy, only the breast on the right side needs a mammogram. When I reminded the tech I had an implant–I had it augmented and lifted so they’d match better–she had to figure out how to bill me. “It isn’t a screening anymore,” she said.

“But I’m still getting screened for cancer,” I said.

She agreed but said now it’s called a diagnostic because of the implant, which explains the letter I got two days later. It said the results are normal/benign, “however, the area of concern in your breast that prompted this exam should be further evaluated by your physician or other health care provider.” They had it in bold type for extra emphasis. Then they said the area of concern “should not be ignored despite a normal mammogram.”

I had to read it twice because it sounded pretty harsh for a good news letter. I briefly thought, “What area of concern? What the heck are you people talking about?” Then I remembered that because of the implant, my visit was classified as a diagnostic visit, not a routine screening. Although I now understand why I got the diagnostic form letter instead of the routine screening form letter, it was a bit jarring. And the tone could stand some improvement in any case. A simple one would be removing all the bold type. If something has prompted a diagnostic mammogram, we get it that we need to pay attention. I”m pondering contacting them with some friendly editing advice.

The other thing I’m wondering about is how the costs of my diagnostic mammogram compare to the costs of a screening mammogram. We used to joke about half-price mammograms after the mastectomy, but I think the opposite might be true. The radiology tech explained that they had to take more pictures. True, but you’re taking pictures of one breast when you used to take pictures of two. I didn’t get into that with her because she is a very nice person and doesn’t make the rules, but I plan to find out what the cost differences are. Call me jaded but I wonder if the diagnostic mammogram doesn’t cost more. I’d be happy to be wrong.

Requiem for Peewee

And say my glory was I had such friends. W.B. Yeats

My human friends weren’t the only ones to see me through my months-long recovery from five breast cancer surgeries. One of my staunchest friends before and after this experience was my cat, Peewee Holstein.

As you can see from the picture, she was my furry guardian while I napped my way through postsurgical recovery, and I napped a lot. If you’ve ever lived with a cat, you know they’re epic nappers themselves and Peewee was no exception. She was happy to have company for her snoozes. My husband Bruce and I were worried about me having to sleep on my back after the big surgeries, since that was her signal to snuggle on my chest. But she was surprisingly good about staying off of it.

Your mind can play tricks on you when you’ve been diagnosed with something big. In my case, my diagnosis came just a matter of weeks after my dad’s death and I was waiting for some other shoe to drop. First I thought how classic it would be if something bad happened to Bruce. Then I decided he would be okay but the cosmic timing gods would take Peewee, who was 16 at the time. But the gods were merciful and let her live.

We eased her out of this life just over three weeks ago, when she was 18. I went home for the afternoon and hung out in bed with her, just as she had with me during my weeks at home. I did a little work on the laptop while she rested against my leg as she had done so many times before. I stroked her and told her what a good girl she was, and weak as she was starting to become, she purred like always. Then Bruce came home and we made the trip all pet owners dread, but it was the least we could do for such a faithful friend.

New Study Offers Glimpse Into Future of DCIS Treatment

Thanks to researchers at the University of California-San Francisco, we have a brand new set of acronyms to add to the breast cancer lexicon. The one you may already be familiar with is BRCA. BRCA 1 and 2 are genes that, when mutated, are linked to hereditary breast and ovarian cancer.

Researchers at UC-SF identified three biomarkers specifically related to ductal carcinoma in situ, or DCIS, a very early stage breast cancer that is confined to the milk ducts. The new biomarkers are called p16, COX-2 and Ki67. (I’d love to know how they come up with these names.) When all three were positive, a woman’s risk of developing invasive cancer within eight years was 28 percent. When all three were negative, the risk was 4 percent. You can read the article at The Journal of the National Cancer Institute. There’s also a more user-friendly article at the New York Times Well blog.

The study is not comprehensive. It included only 1,162 women, the women were treated with lumpectomy only–lumpectomy plus radiation, or mastectomy, are the typical treatments–and it only studied their risk for developing invasive cancer and not recurrent DCIS. Still, it’s a great start.

I’m one of the thousands of women diagnosed with DCIS each year. I chose mastectomy after two attempts at breast-conserving surgery failed to get the desired clear surgical margins. I could have opted for radiation but I wanted a sure bet–DCIS is virtually curable with mastectomy.

Radiation can also be a very good choice but it will depend on your individual circumstance. In my case, I had an awful lot of DCIS. Because of that and some other red flags, one oncologist I talked to estimated my risk of developing invasive cancer within five years at 50 percent.

DCIS is sneaky. Doctors call it “multi-focal”–it could take up residence at one end of a milk duct, or at both ends, and in the middle too. When they biopsied my breast tissue after the mastectomy, some DCIS cells were still lurking in the tissue.

I have absolutely no regrets about the choice I made. But it’s nice to know that in the future, women will be able to make even more informed choices. Just as BRCA lets women make choices based on their genetic predisposition to breast cancer, p16, COX-2 and Ki67 will allow them to make choices based on their individual biomarkers. And that’s good news.