10 Doctors Who Shamed Their Profession

If you think about it, the comparison of doctors to mechanics is pretty apt. Given the specialized nature of their work and the general helplessness of most patients, doctors, like mechanics, are rarely held accountable for their actions. Sure, for the most part, doctors have your best interest at heart, but like in any profession, there are both good and bad apples. According to the National Patient Safety Foundation, 42 percent of people believed they had personally experienced a medical mistake.

Additionally, numerous statistics have shown that a staggering amount of people die each year due to medical error. The following doctors made such blatant mistakes and/or lapses in judgment that they, at the very least, have a reputation that garnered them recognition on this list.

1. Dr. Earl Bradley, Monster: Nothing is worse than violating the trust of a child, which is why Bradley, a former pediatrician from Lewes, Delaware, is such a monster. In February of 2010, he was indicted on 471 charges of child sex abuse involving 103 children. Initial allegations against Bradley surfaced during the mid-’90s, but the hospital for which he worked was unable to verify the claims. They were enough, however, to prompt him to move to Delaware, where more allegations surfaced a decade later, including that he had abused his own son. Bradley was initially arrested in December of 2009 after a year-long investigation, which prompted the indictments two months later.


2. Dr. Robert Ricketson, Screw Up: Ricketson is no longer practicing medicine and the world is better for it. During a spine operation he performed on 73-year-old Arturo Iturralde in 2003, Ricketson intentionally inserted a piece of a screwdriver into the patient’s spine instead of a titanium rod. The rod he had intended to use went missing prior to the surgery, so he took it upon himself to improvise. As a result, Iturralde endured three additional surgeries to insert the proper rod and correct complications. After one of the operations, pieces of the screwdriver were recovered by nurses and the family was alerted. Iturralde became a paraplegic and died two years later, and his family was awarded $5.6 million in a malpractice lawsuit in 2006. During the aftermath, it was discovered that Ricketson’s medical license had been suspended in Oklahoma and Texas and he was denied consideration for a medical license in Kansas in 2002, a year after the botched surgery. He had previously been sued for malpractice several times and had history of narcotics abuse. Not a very impressive resume to say the least.


3. Dr. Jan Adams, Plastic Surgeon Imposter: Adams is most famous for performing the breast augmentation surgery on Donda West, Kanye West’s mom, that resulted in her death in 2007. But that’s not the only blemish on his record. In a malpractice suit against Adams, a previous patient claimed that she didn’t receive proper preoperative or postoperative care, leading to an infection that needed two more surgeries. What’s more, one patient claimed he got her drunk after a surgery and impregnated her, and another claimed a surgical sponge was left inside of her after a breast augmentation. Adams, who attended Harvard University, never received his diploma despite apparently completing his academic requirements. He’s also not a board certified plastic surgeon despite claiming to be one. How was this guy getting work?


4. Julie Ponder and Connell Watkins, Child Killers: Alternative medicine can be a risky proposition given the unproven nature of many of its methods. Attachment therapy in particular can yield tragic results when taken to an extreme. The treatment is used to remedy attachment disorders primarily suffered by adopted and fostered children who persistently misbehave or display little affection toward their new caregivers. In 2000, 10-year-old Candace Newmaker was killed during such treatment when she was suffocated during an intensive rebirthing session. Wrapped in a flannel sheet by psychotherapists Julie Ponder and Connell Watkins, she told to free herself from it while Ponder and Watkins held her down. She pleaded for her life, but was told by Ponder "You want to die? OK, then die. Go ahead, die right now." Newmaker was declared brain dead the next day due to asphyxia. The entire session was videotaped and presented as evidence against Ponder and Watkins, who were each given 16-year prison sentences — Watkins was paroled in 2008 after serving seven years.


5. Dr. James Burt, Ghastly Gyno: The notorious Dr. Burt was exposed for his harmful and downright bizarre practices in the late 1980s when numerous former patients came forward and initiated lawsuits. Beginning in the late 1960s, Burt took it upon himself to perform "love surgeries" in which he altered his patients’ vulvas without their consent. He justified his work in a book he authored in 1975, explaining that "Women are structurally inadequate for intercourse. This is a pathological condition amenable by surgery." He stated the procedure turns them into "horny little mice," though in reality, many of them suffered sexual dysfunction, infection and required corrective surgeries as a result. A $21 million suit was filed against Burt that couldn’t have come close to covering the physical and emotional damages endured by the at least 40 women he hurt.


6. Dr. Cecil Jacobson, Seed Spreader: As a fertility doctor, it was Dr. Jacobson’s duty to assist women in conceiving, and in the 1980s, it appeared he was doing a pretty good job. His patients reported high success rates due to his use of hCG, a hormone released during pregnancy that causes the typical bodily changes. During the supposed pregnancies initiated by hCG, he would identify the fetuses during an ultrasound, but they would usually "die" after about three months. Patients who suspected something was amiss informed a local television station, which investigated and exposed Jacobson. In the process, they discovered he used his semen to artificially inseminate patients who were told they were matched with an anonymous donor. Genetic testing later showed that he was the biological father of at least seven of his patients’ children. Jacobson, who won the Ig Nobel Prize for Biology in 1992 and claimed to have successfully oversaw the impregnation of a male baboon in the 1960s, was stripped of medical license and sentenced to five years in prison.


7. Dr. Rolando R. Sanchez, Accidental Amputator: To be fair to Dr. Sanchez, he has done a fine job of rehabilitating his reputation after the costly mistake he oversaw in 1995 — in fact, he’s still practicing. Even still, it’s the kind of inexcusable error you’d never wish on your worst enemy. In the process of amputating Willie King’s leg, Sanchez was informed by a nurse that he had cut into the wrong one. It was too late, however, and he had to finish what he started — King would later have the original leg amputated by another doctor. Consequently, Sanchez was suspended on the grounds that he presented an "immediate and serious danger to the health, safety and welfare of the public," and King later settled with the hospital.


8. Dr. Red Alinsod, Organ Tattoo Artist: Ingrid Paulicivic certainly won’t be recommending Dr. Alinsod given what occurred during her June 2009 hysterectomy. According to Paulicivic’s lawsuit, while putting the finishing touches on the surgery, Dr. Alinsod decided to brand his work by using an "electrocautery device to carve and burn" her name into her removed uterus. Alinsod claimed the move was necessary to ensure he wouldn’t confuse the uterus with others. Paulicivic became aware of the branding during a follow-up visit in which she complained of the resulting burns on her legs.


9. Dr. Elias Hanna, Carvey Carver: Dr. Hanna nearly caused the premature death of yet another Saturday Night Live legend. In 1998, he botched Dana Carvey’s heart bypass surgery by connecting a healthy portion of his artery to a healthy diagonal vessel instead of the damaged arterial section. It wasn’t until two months after the operation that Hanna discovered the mistake, resulting in an emergency angioplasty for Carvey — his fourth in less than a year. Before it was corrected, he was susceptible to suffering a fatal heart attack. Carvey filed a medical malpractice lawsuit and eventually settled for $7.5 million.


10. 
    

    Alan Hutchinson, Dirty Dentist: Hutchinson, a dentist from Batley, West Yorkshire, UK, made headlines in 2007 when he was accused of using sterilized instruments to clean his ears and fingernails, working on teeth without washing his hands or using gloves, and urinating in a surgical sink. Complaints from a patient and his nurse, Claire Pygott, eventually led to a guilty verdict from the General Dental Council in London. Pygott said that she was "shocked, disgusted and appalled" by the dentist’s actions, which she had witnessed on more than one occasion.

    
    

CMS Releases Revised Medicare Fraud & Abuse Fact Sheet

The Centers for Medicare & Medicaid Services (CMS) recently released a revised Medicare Fraud & Abuse Fact Sheet (February 2010).According to CMS, this fact sheet identifies sources of information pertaining to Medicare fraud and abuse and helps one understand what to do if one suspects or becomes aware of incidents of potential fraud and abuse.

Healthy Meal Plans to Lose Weight

Healthy Meal Plans to Lose Weight Controlled diet and appropriate nutrients when included in a healthy meal plans to lose weight, indeed help people to not just thin down but also stay fit and fine. The weight loss too is in a gradual healthy manner. In the following article, a brief elaboration on healthy plans to lose weight has been provided. To know more, read on… Nutrition, is the primary building block of the human body. The human body which was made to sustain starvation, by reserving nutrition in certain parts of the body, has retained the trait, though some minor evolution in the said trait may have taken place. Fact is, the modern world cultivation and modern agricultural techniques, have ensured that people have sufficient food everyday, though there are certain exceptions to it. Modernization, has not just ensured our daily food intake, but has also to some extend has changed or rather re-engineered the nature of food that we take in.Unbalanced intake and lack of physical exertion aided with unhealthy lifestyle has damaged our bodies considerably. Thus, problems such as obesity, hypertension, diabetes, high cholesterol levels and other such ailments which are quite invited have gripped us. A person should certainly have healthy meal plans, to lose weight, maintain the appropriate balance of food nutrients in the body and also to keep the body well maintained.

When we discuss diets or meal plans, as human beings one must bear in mind certain aspects and some general facts. The human body is not a machine, it's an organism hence you cannot just immediately jump into any diet or routine, instead gradually naturalize yourself into it. Eating only vegetables or fruits or just drinking shakes, eating microscopic proportions of food is a nonsensical approach, you will lose weight, at the cost of damage that you do to your body. Your body needs appropriate nutrition in appropriate quantities. General rule of thumb, eat healthy, eat on time, eat till you are satisfied (not full or not in microscopic quantities).

For an average sized working adult who does a reasonable level of exercise, the 1200 calorie diet menu is a good one. Some other such healthy eating inspired menus include 1600, 1500 or even 2000 calorie meal plans. What kind of meal plan you choose depends upon your daily physical exertion and your body's requirements. It must be noted that all the healthy meal plans for weight loss should be backed by a nice exercise routine as it burns off all the stored fats and calories.

About Food Nutrients

Broadly, food nutrients can be classified into 3 categories, namely, macro nutrients, energy providers and metabolism providers. Here's some more about these categories…

• The first class of nutrients are macro nutrients. The nutrients constitute the several substances that make up the body such as water, carbon, calcium, oxygen, phosphorus, magnesium, potassium, etc. Apart from that there are also several other elements and chemical compounds that constitute the body. Proteins, carbohydrates and fats are also some genuine nutrients that are found in the body. These nutrients are replenished in the body from time to time and a small proportion of the nutrients gets assimilated into the body from the diet. Macro nutrients are something that one might refer to as the 'building blocks of the body'.


• The next category of nutrients is the energy providers. Energy providers include, carbohydrates, fats and proteins. Apart from these prominently known ones simple sugars and other types of energy providing substances that also include vitamins and some minerals also come into this category. A certain care regarding the balance of intake of nutrients is to be taken as excess fats and proteins are taken up as building materials by the body and get stored on our belly.


• The last category is that of metabolism providing substances. These substances are basically the ones which tend to support the fuel burning processes in the body. Minerals, vitamins and water are principle nutrients which provide the support for fuel burning. In case of healthy meal plans for weight loss, you will have to emphasize on the metabolism supporting dietary nutrients as they will help you to burn up excessive fats very easily.

Balancing the nutrients into three categories is one important trick that you will have to learn. Maintaining, good dietary nutrients in balance, exercising in a healthy environment and enjoying the combination of good food and healthy exercise is a great way to burn off excessive weight and also get a good life style. You may also refer to other weight loss diets for more inputs.

Weekly Healthy Meal Plans to Lose Weight

Here are some healthy meal 3 week diet plans to lose weight. These meal plans are meant for all people and in order to reduce weight there are three things that are needed to make the plan a successful one. That is you will have to eat on time, on quality and a satisfying quantity, you will have to exercise, a taking a walk some Yoga and small home based work outs. Lastly, abstain from smoking and alcohol consumption, let it be as occasional as possible. You may also refer to meal planning.

Here are a few, healthy meal plans to lose weight. Note that these, can also be considered to be free healthy meal plans for kids, but with certain modifications. Unlike the 6 meals a day menu, this one has 5 meals and as always, watch what you are eating.

Day Breakfast Pre-lunch snack Lunch Tea snack Dinner

1. Baked beans, multi grain toast, juice, one raw fruit, tea or coffee (emphasize on the protein and vitamin content) A sandwich with only vegetables or a couple of raw fruits and vegetables French tuna sandwich with raw vegetables or even a couple of fruits A sandwich or a cracker or even a crumpet. You may also have a single pancake which is strictly low fat. Layered Vegetable Casserole, with some cottage cheese or a couple of slices of bread or rice. A strict accompaniment is a raw fruit or vegetable salad with no meat or heavy oil. You may also include some small quantities of soup.

2. Bacon and eggs with very less fat, juice, fruit, tea or coffee A raw fruit salad Baked tilapia and a salad with some fats such as oil or small quantities of meat. Start it off with nice warm soup on a cold day. A veggie burger or something small such as a fruit or a muffin. Maple-dill chicken breast and salad with bread or rice.

3. Hard boiled eggs with a bread or toast, go low on cheese or butter. Fruits, cereal or juice accompanied with tea or coffee. A single bakery item which is low fat or low sugar. Grilled sandwich, go low on meat and fat, have a accompaniment of soup or some salad A muffin or again some bakery item Spicy pork and peppers with salad, soup, rice or bread

4. Burrito made up of egg, salsa, beans, etc., juice and fruit. Vegetable salad Sandwich with roasted or smoked meat, low fat and lastly, salad for accompaniment. Some bakery item with a fruit Spinach lasagna with ricotta and mozzarella cheese, go low on cheese

5. Cooked oatmeal with fruit and tea or coffee Raw fruit or vegetable salad Chowder, low fat, low on cheese and meat, with crackers or bread plus a good salad. Salad, sandwich or any bakery item grilled meat in small quantities along with salad and mashed potatoes, go low on fat content

6. Pancakes with minimal fat and less syrup, a fruit A salad or fruit Any stir fry with less meat and fat with rice Fruit or bakery item treat yourself to the meal of your choice, let it be in good proportion and satisfying quantity. On the last day 7, a Sunday you can have your own usual routine of brunch and dinner.

This kind of well maintained and disciplined diet will give you a very gradual and a natural weight loss. There are genuine significance to the nutrition and their balance within the meal. Thus when you start off the healthy meal plans to lose weight, make it a point to take some cautionary measures such as reducing the volume of fat that you consume or the time of the meal.

A breakfast should be as early as 7 am in the morning and very meal should have a 3 to 4 four hour gap in between. Though the article says that eat till you feel satisfied, do not over stuff yourself. Apart from that your exercise should be as regular as possible, a simple walk for the first few months will also do the trick. Good luck.

NovaMed to sell for $214 million

Surgery Center Holdings, an ambulatory surgery center operator, entered into a $214 million deal to acquire NovaMed, a publicly traded surgery center operator based in Chicago. The deal, which is expected to close in the second quarter, includes $105 million of debt.

Surgery Partners, an affiliate of Surgery Center Holdings, would acquire NovaMed stock for $13.25 per share in cash, according to a news release announcing the deal. Private-equity firm HIG Capital, through an affiliate, acquired a majority stake in Surgery Partners in January 2010, according to HIG's website.

Suicidal thoughts more likely to plague surgeons

Surgeons have thoughts of suicide at a rate that is more than double that of the general population, yet few seek psychiatric or psychological help because of concerns that doing so will affect the status of their medical license, according to a report in the Archives of Surgery.

Among the 7,905 surgeons surveyed via e-mail by researchers from the Mayo Clinic and elsewhere, 502 (6.3%) said they had had thoughts of suicide at some point in the previous 12 months, as compared with 3.3% of the general population of the U.S., according to the report.

Of those who thought about suicide, only 130 (26%) sought professional help, while 301 (60.1%) said specifically that they didn't seek help because of license concerns. The report noted that 80% of state medical boards ask about mental illness on license applications, and 47% do so on renewal applications.

Working more than 40 hours a week and having a greater frequency of being on overnight call led to more-frequent thoughts of suicide, but one of the highest factors contributing to suicidal thoughts was having experienced a major medical error. Among surgeons who said they had a major medical error in the three months before the survey, 16.2% reported having suicidal thoughts in the previous year, compared with 5.4% among those not reporting an error.

The researchers also noted several ways in which surgeons do not fit common suicidal profiles. Among physicians, the report said surgeons appear to have the lowest rates of substance abuse and dependency. Surgeons also are highly educated and "nearly universally employed," and 88% are married—all factors that reduce suicide risk in the general population, according to the report.

The report concluded that more study is needed to be able to identify why surgeons have higher rates of suicidal thoughts and how to lower barriers to using mental health services.

"We are human; to err is inevitable; and suicide is not the right answer for those tormented by the expectation of perfection," University of Pittsburgh School of Medicine physicians Dr. Kelly McCoy and Dr. Sally Carty said in a commentary accompanying the report.

Watermelon lowers blood pressure

Amino acids found in watermelon have been shown to lower blood pressure. In addition to healthy vitamins and minerals, watermelon contains two amino acids, L-arginine and L-citrulline, that reduce hypertension.Other Natural Blood Pressure Lowering Foods
Other foods have also been shown to lower blood pressure. Bananas can lower hypertension, as can raisins, beets and even chocolate.

Watermelon Research
Researchers at Florida State University used a concentrated extract of watermelon for the research on nine subjects. The dosage used in the study was six grams of the combined watermelon amino acids. After six weeks, all of the participants, 100 percent, showed reduced blood pressure. The study concluded that watermelon could be used by people who have pre-hypertension to keep the condition from progressing to high blood pressure. This means that eating watermelon may allow those at risk for heart disease to avoid taking preventative blood pressure lowering medications that are usually prescribed.

Blood Pressure Prevention Medication Side EffectsPharmaceutical drugs are frequently prescribed for those with a tendency towards high blood pressure, a condition called pre-hypertension. These medications have been shown to have numerous side effects, including potassium loss that leads to an increased risk of diabetes. Other side effects, reported by Johns Hopkins University, include constipation, frequent urination, headaches, digestive upset, dizziness, and a tendency to dehydration, which causes a number of health issues in itself.

Watermelon, on the other hand, has no known side effects. Watermelon Contains Vitamins and Lycopene Watermelon also contains healthy nutrients, such as vitamins A, vitamin C and vitamin B6, along with potassium and fiber. Watermelon also contains lycopene, the nutrient plentiful in tomatoes that has been show to have numerous health benefits. Lycopene is an antioxidant. Eating foods high in lycopene has been shown to reduce the incidence of many types of cancer, including breast cancer and prostate cancer. Lycopene has been shown to prevent heart attacks both in studies at John HopkinsJohn Hopkins University and in international studies.

Though tomatoes were used in the studies, other foods known to be rich in lycopene are watermelons, grapefruits, apricots and guavas. Watermelon Mechanism of Action Watermelon lowers blood pressure because of its action in production of nitric oxide, researchers surmise. This is because L-citrulline in the watermelon is converted into L-arginine, which is then used to make nitric oxide. Nitric oxide, in turn, helps control blood pressure. L-Arginine Alone is Not Enough Taking the amino acids L-arginine by itself is not an effective treatment for high blood pressure, nor is it recommended because the amino acid is not easy to digest and can cause digestive problems, including diarrhea. Watermelon Dosage to Prevent High Blood Pressure The dosage used in the watermelon study was four to six grams of watermelon extract, but a healthier alternative is to add raw watermelon to the diet.

If you do not brush your teeth, you can die!

If you regularly brushing and flossing, you can save your life. To such an unexpected conclusion scientists. Although the fact that gingival condition directly related to the state of the cardiovascular system, experts have long suspected, confirmation of these conjectures were first obtained.

Experts from Bristol University say that's all my fault protection mechanism of the human body from germs. When the patient's gums bleed, bacteria enter the bloodstream. In response, the formation of clots tromobotsitov, which should prevent the spread of harmful germs. However, there is this process and the other side - platelets clog blood vessels, causing them to extinction.

The head of the research team, Professor Howard Jenkinson said: "Such an arrangement perfectly protects from bacteria and provides immunity." However, according to a scientist, a large number of blood clots can cause growths on the vessels, their inflammation and thus block access of blood to the heart and brain.

Speaking at the autumn conference of the Central Society for Microbiology, held in Nottingham, Professor noted that the only escape from such risks may become a regular oral health care.

Of course, the conclusions of professors were not unfounded. The expert team under his leadership has used the model of blood flow, developed at the Royal College of Surgeons Ireland. It fully emulates the human body. Harmful bacteria have been placed in this artificial blood.

Streptococci, monitored by scientists, who live on the teeth of any person. It is they who are guilty of gum disease and plaque formation.

Recall that the scientists from University College London, earlier confirmed the conclusion of his colleagues that the people who rarely brush their teeth, often suffer from heart disease than those who jealously watching oral hygiene.

The study, which lasted eight years, experts have analyzed the medical records of more than 11,000 people under the age of 50 years. Experiment participants were asked how often they visit the dentist and brushing their teeth.

In the study took into account such factors adversely affecting the heart, as obesity and smoking. But in most cases of serious heart problems, who observed the scientists, the crucial role is played by attitude towards oral health.

Coding for Sleep Medicine Testing and Treatment

Sleep medicine is a new field, and some important aspect of sleep medicine coding changes almost every year. This review will focus on policies of the Centers for Medicare and Medicaid Services (CMS), formerly the Health Care Financing Administration or HCFA. CMS pays for only 10-20% of a typical sleep center's studies, but CMS policy decisions influence other third-party payers.

Physicians can bill for services in diagnostic sleep testing in one of three ways. First, physicians providing services in their offices or freestanding sleep centers bill for the global service - both the professional work (interpretation) and the technical component - using the appropriate CPT code, such as 95810, without a modifier. Physicians interpreting diagnostic tests in hospital-based sleep centers or in some freestanding centers, will bill using CPT 95810-26; the -26 modifier means the bill is for the professional work only. Owners of some freestanding centers will bill for their technical fee as 95810-TC; the -TC modifier indicates that the bill is for the technical component of service only. Although freestanding centers and independent physicians may bill CMS for their separate component fees, most third party payers insist on getting a single bill, for the global fee.

Current CPT codes are listed in the following table. Codes 95806 and 95807, which do not require sleep staging, are termed "Sleep study." Codes 95808, 95810 and 95811, termed "Polysomnography," require sleep staging including electroencephalography (EEG) (1-4 leads), electro-oculography (EOG), and electromyography (EMG). In addition to sleep staging, code 95808 records 1-3 additional parameters of sleep, code 95810 records 4 or more additional parameters of sleep, and code 95811 records 4 or more additional parameters of sleep and CPAP use. New 2002 CMS policies for CPAP payment require that the sleep apnea diagnosis "must be based on a minimum of 2 hours of sleep recorded by polysomnography" (italics added), so the distinction between sleep studies and polysomnography is important to patient care.

Code 95806 describes an unattended sleep study, but all other codes require a technologist to be in attendance. (A home sleep study remotely monitored by an offsite technologist is not an attended study.) All codes require recording for 6 hours or more. The modifier, -52, may be used to code a limited service. For example, when a patient is intolerant to CPAP and stops a titration polysomnogram before 6 hours of recording has been completed, the procedure should be coded 95811-52. Tests performed to screen for a diagnosis, such as sleep apnea, must be coded with a "V" code - but CMS rarely pays for screening tests, even if a significant pathologic diagnosis is made.

Sleep Testing Codes, CPT 2002
CPT Code	Description
95805	"Multiple sleep latency or maintenance of wakefulness testing, recording, analysis and interpretation of physiological measurements of sleep during multiple trials to assess sleepiness."
95806	"Sleep study, simultaneous recording of ventilation, respiratory effort, ECG or heart rate, and oxygen saturation, unattended by a technologist."
95807	"Sleep study, simultaneous recording of ventilation, respiratory effort, ECG or heart rate, and oxygen saturation, attended by a technologist."
95808	"Polysomnography; sleep staging with 1-3 additional parameters of sleep, attended by a technologist."
95810	"Polysomnography; sleep staging with 4 or more additional parameters of sleep, attended by a technologist."
95811	"Polysomnography; sleep staging with 4 or more additional parameters of sleep, with initiation of continuous positive airway pressure therapy or bilevel ventilation, attended by a technologist."

 

Some "Additional physiologic parameters" are listed in below. While CPT codes require that a certain number of parameters these parameters be recorded, the codes are not specific about the method of recording. For example, technologist observations of snoring intensity and body position may be adequate as two physiologic parameters of sleep for a polysomnogram.

ADDITIONAL PHYSIOLOGIC PARAMETERS, FOR POLYSOMNOGRAPHY
EKG	Extended EEG
Airflow	Penile tumescence
Respiratory effort	GE Reflux
Gas Exchange by	Continuous BP monitoring
Oximetry Transcutaneous monitors End-tidal gas analysis	Body Position Other
Limb muscle activity	ÂÂ

Based on a 2002 conversion factor of $36.20, the following table summarizes CPT requirements and CMS payment scale for diagnostic sleep studies and polysomnography.

Hospitals bill for the technical component of outpatient sleep studies under the relatively new system of Ambulatory Patient Classification (APC) Groups. To simplify coding and reimbursement for hospital outpatients, CMS grouped the CPT codes, numbering about 7500, into 451 APC codes. Each APC contains two to fifty (2-50) procedures. CMS established a national payment rate for each APC, adjusted geographically for the wage index. The payment includes costs for supplies, drugs, and room charges, but not professional fees, clinical lab fees, durable medical equipment, or rehabilitation services. The hospital is paid for each procedure based on the 1996 median hospital cost of all the services in the APC. One result is that book-keeping is simplified: hospitals bill for, and CMS pays for, only 451 separate fees rather than 7500 separate fees. Under the previous payment system, Medicare hospital outpatients were to pay 20% of hospital charges, but now benefit coinsurance will be gradually adjusted to 20% of the APC rate. Since charges often greatly exceeded hospital costs, hospital outpatients usually will pay lower fees under the new system.

For 2002, the technical charges for most sleep studies are in APC Group 0209 - Extended EEG Studies and Sleep Studies, Level II. The following sleep diagnostic tests are in this APC Group: 95805-TC, 95807-TC, 95808-TC, 95810-TC, 95811-TC. Among the prominent sleep testing codes, only the unattended sleep study is excluded. All-night sleep EEG, 24 hour EEG with video monitoring, and 24-hour EEG with computer analysis, are the only other codes in this group. The 2002 APC rate for the technical component of any service in this group is $537.

Also for 2002, CPT code 95806-TC, the technical component of the unattended sleep study, is in APC Group 0213 - Extended EEG Studies and sleep Studies, Level I. Five other EEG codes complete this group. The 2002 APC rate for the technical component of any service in this group is $135. CMS does not approve payment for CPT code 85806 when charged separately by a freestanding sleep center, but hospitals may be paid for performing this service on outpatients by billing the APC code.

Charges for pulse oximetry performed in the physician office should not be billed separately, but rather should be included as part of services during an office visit. An exception to this rule is CPT code 94762: "Noninvasive ear or pulse oximetry for oxygen saturation; by continuous overnight monitoring (separate procedure)." The value of our organized lobbying was demonstrated when CMS restored separate reimbursement for overnight oximetry in response to comments by the Academy of Sleep Medicine - and when CMS decided to pay about $6.90 for it in 2002.

CPT code 99508 is "Home visit for polysomnography and sleep studies," conducted by a nonphysician. The CPT editorial panel in 2001 recommended that it be deleted.
A small but increasing number of physicians provide durable medical equipment through their office practice or freestanding sleep centers. Coding for PAP supplies is complex. To code for oral appliance therapy, including fitting, use CPT Code E1399: "Durable medical equipment, miscellaneous," or HCPCS Code S8620 "Oral orthodontic for the treatment of obstructive sleep apnea." CMS does not allow payment for oral appliances, but local insurers may approve reimbursement using one of these codes.

Clinicians and manufacturers for actigraphy, oral appliance therapy, pharyngometry, and other services have requested new CPT codes. Since the expansion of CMS funding is limited, it appears likely that payment for any approved new services will come from the sleep medicine "bucket," reducing payments for existing services.

To be eligible for Medicare payment a sleep study must be performed at a "sleep disorders clinic." The term is defined by CMS as a facility in a hospital or under the control of a medical director. CMS also requires that polysomnography and sleep studies be performed under the "general supervision" of a physician, meaning that the physician is responsible for the direction and control of the procedure, but the physician's presence is not required during the test.

In 1999 CMS published its policy for services performed in a facility independent of a physician's office or hospital, in a newly defined "Independent Diagnostic Testing Facility" (IDTF). For sleep testing to be performed in an IDTF, CMS requires that the physician supervisor be certified by boards in psychiatry and neurology, internal medicine with pulmonary subspecialty, or in sleep medicine. CMS also requires that IDTF technologists must be certified in electroneurodiagnostic testing or registered in polysomnography.

To pay for CPAP, CMS previously required that a patient have "30 apneas" per 6 hours of recording. Under a new 2002 policy, CPAP will be approved for patients with an apnea/hypopnea index (AHI) of 15 or more, and for patients with an AHI of 5-14 "with documented symptoms of excessive daytime sleepiness, impaired cognition, mood disorders or insomnia, or documented hypertension, ischemic heart disease or history of stroke. The AHI is equal to the average number of episodes of apnea and hypopnea per hour and must be based on a minimum of 2 hours of sleep recorded by polysomnography using actual recorded hours of sleep (i.e. the AHI may not be extrapolated or projected). Apnea is defined as a cessation of airflow for at least 10 seconds. Hypopnea is defined as an abnormal respiratory event lasting at least 10 seconds with at least a 30% reduction in thorocoabdominal movement or airflow as compared to baseline, and with at least a 4% oxygen desaturation. The polysomnography must be performed in a facility-based sleep study laboratory, and not in the home or in a mobile facility."

This revised CPAP payment policy tasks referring physicians to order polysomnography, not sleep studies, to diagnose sleep apnea. If CMS interprets this policy literally, any diagnosis made using data from a 4-channel cardiorespiratory "sleep study" or from home "polysomnography" must be confirmed by an attended polysomnogram in the laboratory, possibly in a split-night protocol. The policy puts new burdens on testing facilities to revise their scoring rules to comply with CMS definitions, and to ensure that split night studies include a baseline of 2 hours of sleep. Since it is unlikely that facilities will use separate scoring rules only for Medicare patients, most facilities now must standardize their definition of hypopnea. To reduce difficulty for the patient, DME provider and prescribing physician, each report should clearly state the facility scoring conventions, the technical description of the recording, the patient's symptoms, the number of apneas, and the AHI.

Not only must the interpreting physician code the study correctly - effective January 1, 2002, "a new [CMS] national policy states that a doctor who interprets it should bill using the ICD-9 code for the final, related diagnosis - not the reason for the test... symptoms that prompted the ordering of the test may be reported as additional diagnoses." Releasing this policy, CMS has reinforced the primacy of ICD-9-CM for diagnostic coding and has reinforced the injunction to code to the highest level of accuracy and specificity. The same policy also requires that a testing facility must document the testing order from the referring physician.

Sleep specialists are faced with two sets of diagnostic coding. The ICSD - International classification of sleep disorders: Diagnostic and coding manual, edited by Thorpy, was published by the American Sleep Disorders Association, now the AASM, in 1990. A revised edition was published in 1997, and an update process has begun. The ICSD has been very helpful for sleep specialists and for sleep research, but most medical specialties and insurers rely on the International Classification of Diseases, 9th revision, Clinical Modification - the ICD-9-CM. The tenth revision of ICD is due in 2002. Most clinicians use ICD-9-CM coding for clinical purposes, since insurers rely on it to match services with diagnoses, and since Medicare requires the ICD-9-CM code. Note, however, that the AASM may require accredited centers to use the ICSD diagnostic codes. The following table lists some common sleep disorders and their codes. Some notes on coding:

• There is no separate ICD-9-CM diagnostic code for central sleep apnea. Code for obstructive or central sleep apnea depending on whether the patient has insomnia or hypersomnolence.


• There is no specific ICD-9-CM code for primary snoring without significant sleep apnea. The suggested code is a nonspecific code under "Symptoms involving respiratory system and other chest symptoms."


• The suggested ICD-9-CM code for restless legs syndrome is a nonspecific code under "Other extrapyramidal disease and abnormal movement disorders,"" but the definition of the nonspecific codes mentions the condition: "333.99, Other, Restless legs." This may also be the best code for periodic limb movement disorder, a movement disorder occurring during sleep, which is not specifically listed in ICD-9-CM.


• There is no specific ICD-9-CM code for idiopathic insomnia as defined in the ICSD. Specific codes for transient or persistent insomnia are listed in ICD-9-CM "307.4 Specific disorders of sleep of nonorganic origin."

Clinical Diagnosis	ICSD Code	ICD-9-CM Code
Obstructive sleep apnea syndrome	780.53-0	780.51 Insomnia with sleep apnea 780.53 Hypersomnia with sleep apnea 780.57 Other and unspecified sleep apnea
Central sleep apnea syndrome	780.51-1	780.57 Other and unspecified sleep apnea
Primary snoring	780.53-1	786.09 Other Excludes respiratory distress and failure
Narcolepsy	347	347 Narcolepsy
Restless legs syndrome	780.52-5	333.99 Other Restless legs
Periodic limb movement disorder	780.52-4	333.99 Other Restless legs
Idiopathic insomnia	780.52-7	780.52 Other insomnia Insomnia NOS

Private insurers often develop proprietary coverage policies about sleep medicine, and they often do not disclose them freely. Aetna/US Healthcare, to its credit, has posted its "Coverage Policy Bulletin" on its website. Local professional relationships are important to the sleep center and to the insurers; with persistence and good will, we can help the insurer medical directors to develop policies helpful to our patients. Please help to influence national sleep medicine policies: join the American Medical Association and register as a specialist in sleep medicine, join the AASM, and contribute to the AASM's Political Action Committee.

References

1. Raphaelson, M. Sleep Center Management. AASM 1998. 2nd ed 2000.


2. Inglehart, J. The Centers for Medicare and Medicaid Services. NEJM 345: 1920-1924, 2001.


3. Tunis, S. et al. Continuous Positive Airway Pressure (CPAP) Therapy Used in the Treatment of Obstructive Sleep Apnea: Coverage Decision Memorandum for CPAP, 2001. http://www.hcfa.gov/coverage/download/8b3-bbb1.rtf 


4. ICSD - International classification of sleep disorders: Diagnostic and coding manual. Diagnostic Classification Steering Committee, Thorpy MJ, Chairman. Rochester, Minnesota: American Sleep Disorders Association, 1990.


5. International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) 6th Edition (2001 Update. Department of Health and Human Services, National Center for Health Statistics (NCHS). October 1, 2001.


6. Medicare Part B News.15:pages 1 and 7, October 1, 2001. Policy B-01-61 is available through: http://www.partbnews.com 


7. Shepard, John. President's Perspective. AASM Bulletin, 4-5, Winter 2002. (Discusses the 2002 CMS CPAP payment rules.)

Attribution

Marc Raphaelson, MD is medical director for Greater Washington Sleep Disorders Centers in Metropolitan Washington, DC. He is a member of the AASM's Health Policy Committee.

Marc Raphaelson, MD
Greater Washington Sleep Disorders
Washington, D.C.

Primary-care docs lead pack for EHR money

Primary-care physicians are the clinicians most likely to seek early reimbursement from the federal government for the adoption of electronic health-record systems, according to a survey conducted by the Centers for Disease Control and Prevention's National Center for Health Statistics.

Data from the 2010 survey were discussed by Dr. David Blumenthal, head of HHS' Office of the National Coordinator for Health Information Technology, at a news briefing in Washington on Thursday.

"This latest survey reveals that primary-care physicians have broken out of the pack," Blumenthal said.

The American Recovery and Reinvestment Act of 2009 established the incentive program through which doctors and hospitals can receive payments for the adoption and meaningful use of EHR systems.

Ultimately, Blumenthal said, most physicians "in the prime of their practice" and hospitals are likely to participate in the EHR incentive program.

Stephen Lieber, president and CEO of the Healthcare Information and Management Systems Society, said he expects "close to 100%" of hospitals will end up participating in the program.

"Especially with the penalty phases that kick in down the line, I don't see how any hospital can afford not to participate," Lieber said.

About 8,300 hospitals and physicians have registered with the program through the CMS since registration opened Jan. 3, according to a CMS spokesman.

MU Health Care inspection report reveals hygienic problems

COLUMBIA — A registered nurse at University Hospital entered a patient's room without a hand-washing, removed the patient's IV lock without wearing gloves and left the room, again without washing. The nurse then went into another patient's room, opened a drawer, grabbed a flashlight and brought it back into the first patient's room.

The detail is among scores in a Centers for Medicare & Medicaid Services report from November 2010 that MU Health Care representatives said Monday they are addressing in preparation for a follow-up inspection by the regulator. The inspection report was obtained by the Missourian through a Freedom of Information Act request from the Centers for Medicare & Medicaid Services.

"It's (hand-washing and gloves) so basic," a clinical improvement specialist told an inspector in a subsequent interview, according to the report. "I don't know why this happens."

The centers conducted an unannounced, on-site survey from Nov. 1 to Nov. 5 after receiving a complaint from a former employee, MU Health Care CEO Jim Ross confirmed.

Though the complaint was unsubstantiated by the inspection, other problems were cited with infection control and physical environment standards. Inspectors found expired supplies, inconsistent hand-washing procedures, dust on surfaces in the surgical unit, dirt and debris in kitchen preparation areas and stains on floors and equipment.

Hospital administrators said a follow-up inspection will occur within 60 days of the report was received, which was Dec. 6.
"These are issues we take seriously," said Dr. Les Hall, chief medical officer for MU Health Care. "We are going to do our due diligence to make sure that it's corrected."

Dr. Hal Williamson, vice chancellor of MU Health System; Carey Smith, manager of regulatory affairs; Jo Ann Wait, spokeswoman for the hospital, Ross and Hall met Monday with Missourian reporters to talk about the report. They emphasized it was being taken seriously, though some observations were minute in detail.

About 120 University Hospital and Clinics employees put in overtime and unpaid hours in December cleaning up facilities, according to earlier reports in the Missourian.

"The staff has done great, and we may not agree with how (inspectors) looked at us and elevated the issue, but if they brought it up we are going to address it," Ross said.

He said hospital staff members have reviewed the national standards for hand-washing and are increasing their scrutiny of hand-washing habits by other employees.

Among the other problems cited by the inspectors:
Report: Black and brown residue accumulated in cracks where heat-sealed vinyl floor strips had separated in an operating room. Several tiles were buckled and black-colored debris was found in the sterile storage area.
Ross: Although some of the floors in question typically never come into contact with patients, they have been replaced.
Report: Dark red and brown dry spots were found on two infusion pumps at the Missouri Orthopedic Center's Post Anesthesia Recovery Unit. An interview with a supervisor stated that the "pumps had been cleaned by housekeeping and the spots on the pumps appeared to be either dried blood or Betadine."
Ross: Multiple staff members told the inspector that the spots were Betadine, an antiseptic used in surgery.
"When I've got staff telling them it's Betadine, not blood, and it still comes back in a report as it may be, it's very suggestive," Ross said.
Report: Dust was found on multiple surfaces throughout the facilities, including "the top horizontal surfaces of an anesthesia cart and a fluoroscopic camera." The report states, "When the surfaces were wiped, dust particles fell to the floor and onto the surgical table."
Hall: "All of us would say that the amount of dust they found in some areas of the hospital, even though many of those areas were not direct patient-care areas, is something that we want to take care of."

The hospital administrators said problems observed in the report have not affected their out-patient infection rates.

The centers will conduct a second unannounced inspection, and the hospital has been preparing, Ross said.

"We are absolutely prepared for it," he said. "The staff is anxious to get the survey team here because they want to show them (the improvements)."