Dog Walking

A little over 3 years ago my husband and I had acquired a 4-month old Yellow Lab named Zoe.   A friend and co-worker offered her up with no price tag and no catches attached after his wife had brought her home, which would’ve made Zoe their 3rd pet in the house, and their financial situation at the time was already in dire straits.   A year before this we had our beloved German Shepherd Zeus euthanized due to sudden illness, so when Zoe came along we were both ready to have a pet again.

Zoe has always been a clingy dog, and is very affectionate with just about anyone she meets.  Since my husband’s death our bond has grown much stronger.  One of my many regrets is that Richard and I didn’t take her out much for walks.  She gets plenty of exercise, but she never really had a chance to become more familiar with our immediate neighborhood while Rich was still alive.   Well, that is no longer the case.

Maybe it was the positive change in the weather.  Maybe it was my need to fill a huge void in my life.  Whatever it was that made me get up off my duff and grab the leash, Zoe and I will be forever grateful to that much needed kick- in- the- pants.  Two weeks ago I took Zoe for a walk just around our block a couple of times to see how she would react, and of course the exercise was beneficial for both of us.  She ended up dragging me most of the way, with her nose encountering such a frenzy of new smells that she barely lifted her head up during the entire stroll.  The week after that, I took her to our local park on a brisk and beautiful sunny evening, which opened her up to even more unusual sights and scents–not to mention other dog-walkers.  Many of them submitted to Zoe rubbing noses with their dogs, obliging her relentless need to get better acquainted, even though she towered over all those she met (the top of her head is about 3 feet from the ground, and she weighs 90 pounds).  Despite her brutal strength I never lost control over her, and it was such a treat for her to finally make some ‘friends’.  The warmer weather soon to come will hopefully open more doors for the both of us.

  zoe2

Cheating Death

Over the past few weeks I’ve had lots of time to reflect about some serious events that have taken place over the course of my 39 years, and it has reminded me of the fact that I am very lucky to be alive. 

As an infant in the early 70′s, I contracted a severe case of chicken pox . At my worst, I had a fever of 105 and was unresponsive.  Given my age at that time I of course didn’t recall this at all, but I have a keepsake scar on my forehead that my parents like to point out everytime they tell the story.

At the age of 17 I was diagnosed with Crohn’s Disease.  I remember a few vivid details prior to and after my hospital admission, but the rest is a blur.  I was admitted to the hospital at the start of my senior year in high school with a temp of 106 and severe dehydration.  Once I was diagnosed and prescribed a multitude of medications, it wasn’t long before I bounced back.  A few years later during my junior year in college I had no choice but to quit my education and part-time job because the disease became so active I was no longer responding to any oral medication.  The following year my entire large intestine was removed–I was so ill that death was the only alternative.   

However since then, I’ve only had to deal with some extra-intestinal manifestations, like pyoderma gangrenosum.  Fortunately, I am one of the lucky ones who respond well to drugs like Remicade, or infliximab. It has kept the disease very manageable for the last 8 years.  

I realized that at any of those times I could’ve succumbed but for whatever reason, I am still here.  I am eternally grateful to the all medical professionals who were, and still are involved in my care; they’ve had a profound impact on the way I view life– and death.

The Seven Elements

I have been meaning to write about this for some time. In fact, this was one of the reasons I wanted to create this blog.

I don’t think I’ve ever met any clinician who’s actually enjoyed fullfilling their documentation requirements for whatever medical matters pertain to their patients.  And for those of you reading this who are licensed practitioners, you know the future’s not so bright regarding this subject.  So who are we to blame for all this?  Our Federal and State government funding programs?  JCAHO?  Or do we blame the consumers who’ve been cheating the system for decades?  Form your own opinion.

Now let’s get down to business.  My workday consists of handling medical documents of all sorts.  A cornucopia of prescriptions, letters of medical necessity, physical/occupational evaluations, examination dictations, and so on.  The clients I mainly deal with are those who are permanently disabled, whether congenital or acquired, and are in need of some type of equipment to improve the quality of their lives.  Whatever the equipment, be it a posterior walker, manual wheelchair, or custom power wheelchair, my clients’ need for said equipment solely relies on what documentation I can gather to support their claims. 

I’m going to focus on one particular funding source, because it seems that so many others in the health insurance industry are following it’s wretched path, and that is Medicare.  Just the mere mention of this source stirs up endless negative thoughts.  Anyway, Medicare has kind of  ‘streamlined’  the process, especially for wheelchairs.  For the past 3 years, we’ve no longer had to send those dreaded CMN’s, or certificates of medical necessity, which were essentially an array of multiple guess questions and drop-down boxes that were often too vague to answer.  Some types of equipment like power wheelchairs, were once limited to specific diagnoses.  That limitation no longer exists and the CMN’s are no longer used, but today’s requirements actually make it more complicated to produce justification.  So much for streamlining.

Enter the Seven Elements.  These are the necessary components for a ‘powered mobility device’ (scooter or wheelchair) prescription to be valid and they are as follows:  

  1. Patient’s name.
  2. Pertinent diagnoses.
  3. Length of need (must be lifetime).
  4. Date of Face-to Face exam.
  5. Description of the item (can be general or specific).
  6. Physician’s signature (NO stamps! E-sign is acceptable).
  7. Date of physician’s signature (again, no stamps!).

Sounds simple enough, right?  Not so fast.  Everything that is documented on the prescription must be supported by the examination chart notes.  For example, the patient’s condition must severely limit their ability to perform any Mobility-Related Activities of Daily Living within their own home setting, either completely or in a timely manner.  Or, the patient’s limitation puts him/her at high risk of morbidity/mortality when attempting to perform these activities without the use of the prescribed device.  And you can’t just paraphrase this in the exam notes; the notes must specifically state how this limitation or condition prevents the completion of one or more MRADL’s.  Furthermore, the chart notes must explain how other less-costly alternatives (canes, walkers, manual wheelchairs) have been tried and/or considered and ruled out.  And last but not least, the patient’s home must be assessed for accessibility.  That’s right.  If the patient meets all the required medical criteria but their home cannot accomodate any type of mobility device, the claim is now unjust, unless provisions are made before the equipment is obtained.  Home modifications are very costly, even for the most simple cases, and are not covered by Medicare or most other insurance plans.  Now folks, this is just for your basic powered device, such as a motorized scooter, or a consumer power wheelchair (ones that have no custom components).  Custom manual and custom power wheelchairs require a physical or occupational therapist’s assessment in addition to the aforementioned documentation.  An equipment trial period may also be warranted.  The problem with this idiocy is that most providers don’t stock this kind of equipment for a ‘test drive’.  Hence the word custom.  Are you listening, Medicare?  Now I can’t stay up all night and list every stinking detail, which is why I provided the link above.  Scroll through it and you’ll find all the information you need when ordering this type of equipment, if you can spare a couple of hours.  A tip for all  physician’s out there:  if ANY of the seven elements are missing from your Rx, your patient’s claim will be denied as not medically necessary.  I’ve seen it happen.  Finally, all the documentation that is produced after the face-to-face exam must be fowarded to the medical equipment supplier no later than 45 days after the exam, or it’s back to the drawing board you go.  One good thing (well, not that good) is that this ‘exam’ must be billed with an add-on CPT code, G0372, in addition to the office visit charges.  The last time I checked the Medicare fee schedule for this add-on, it was a little over $20.  I’m SURE that’ll make up for all the documentation efforts.

A Tribute

Any readers out there who’ve read the last few posts regarding my husband and may be wondering about his status, he has passed,  just two days after Christmas.  The week of Christmas and the week after that was the worst time of our entire life together.  Long story short, he suffered a cerebral hemorrhage due to autonomic dysreflexia, which led to swelling of the brain tissue. He went into a coma on Christmas day and my families and I said our final goodbyes two days later.  

Now I could just write away and tell you all the horrific details but I’m not going to do that.  I’ve had to re-live those days over and over so many times I don’t have the emotional strength to do it again.  Instead I’m going to tell you about my husband, whose name is Richard, and this is my tribute to him; to follow his example and make a difference in this world.

Richard was involved in a single-car accident almost 27 years ago which  left him wheelchair dependent, but didn’t stop him from living.  At first he had a hard time dealing with his injury, as anyone would.  But it was his mother who encouraged him to persevere (I was no where in the picture until 12 years later).  While on social security disability for about a year he went back to work and earned a college degree.  Although becoming quite independent, he still required some assistance so he remained at home with Mom, Dad and two siblings.  He obtained an equipped van through a charity event. Everywhere he went he made friends.  He inspired others to go on no matter how bad they thought their lives’ were, and many told him that.  He literally had a smile that would light up a room, and wherever he worked, he was a major impact on company morale. He lived to make people laugh and would do just about anything for a laugh.  The stories are absolutely endless.   Now Richard wasn’t annoyingly perky.  He was just always upbeat. He was a regular client where I had worked and was such a flirt.  I had just gone through a bad break-up ( now I know what you’re thinking but this was no rebound) and everytime Rich would stop in he’d always ask me, ” how’s your love life?”  At first I shyed away, but eventually I came clean and he didn’t hestitate to ask me out.  I admit I was a little apprehensive, but I thought, why not?  His confidence and sense of humor was quite attractive.  We had such a great time and no matter where we went from then on, the public always smiled at us.  Maybe it’s because we were always smiling. I don’t know. I guess optimism can be contagious.  It was for Richard, even though life sometimes dealt him a bad hand with regards to his health. 

As I look back, his health was the only problem that caged him sometimes, which I could fully understand, and some birds just aren’t meant to be caged.  We were married 10 years ago, and what a ride it’s been.  I hope to go on as Richard would have, if the tables were turned. My tribute to Rich is to make the most of each new day and be a positive impact on someones life as he was on mine and so many others.  Richard had no enemies, and that’s no exaggeration at all.  It took all four of the calling hours for everyone that came, to pay their respects.  That, in itself, speaks volumes.

Hemoccult Handshake

How YOU doin'?
How YOU doin’?

Just an update on DH, he was taken care of very well in the ED this past Saturday. Given that he had to spend the night there, the staff made sure he had an appropriate bed to sleep in. This was the first time since we’ve been married that I haven’t had to tell any hospital staff about his skin protocol.  It was such a breath of fresh air, & peace of mind. Now I know this is something that is not intentionally overlooked. It’s just low on the priority pole in ANY hospital ED we’ve been to;  they’re usually so busy ordering radiology tests, drawing blood, documenting, etc., & most ED’s in our area have to order a special bed from a supplier whether he has a room or not.  I worry about his butt–literally.

Anyway, the day after I brought him to the ED, he required one more test before finishing his admittance paperwork–they had to check his stool for blood. To break the awkwardness, the physician assistant said, ” this is the (insert hospital name) handshake”, which of course made everyone chuckle. The ol’ hemoccult handshake. Nice to meetcha Mr. Smith, I gotta wash my hands now…..

I’ve Been Memed…..

1. Hot chocolate or egg nog? Hard to choose. I like them both a lot, but I think I’d prefer egg nog, with the rum.

2. Does Santa wrap presents or just set them under the tree? Duh– every body knows Mrs. Claus dons her red dominatrix dress & cracks the whip on those little elves. Very naughty!

3. Colored lights on house/tree or white? Well, we have white ones on our tree, but it’s pre-lit, so we took what we could get at that time. I don’t have lights on the house, but I like all kinds no matter the color.

4. Do you hang Mistletoe? No. But I already get lots of kisses.

5. When do you put your decorations up? Generally at the start of December, but sometimes after Thanksgiving.

6. What is your favorite holiday dish? Even harder than #1. I’d have to say homemade cranberry relish.

7. Favorite holiday memory?  Spending my first Christmas in my own home after I was married.

8. When & how did you learn the truth about Santa?  I don’t actually remember, except that I was very young because we always found out where the presents were hidden.

9. Did you open a gift on Christmas Eve? Yes.  In fact, as everyone got older, it became more of a tradition to open gifts after the late church service. By then it was after midnight so technically it was on Christmas Day.

10. How do you decorate your Christmas tree? Pretty much by the book: lights first, garland, ornaments, tinsel, then the skirt.

11. Snow:  love it or dread it? Love a little of it, dread lots of it.  I don’t like being couped up.

12. Can you ice skate? Yes, & very well.  Oh I’m no Peggy Fleming, but I grew up skating on outdoor rinks & frozen ponds/lakes. Now we have two indoor rinks in my area.

13. Do you remember your favorite gift? Yes. My first bicycle (sappy,  I know).  It was a great bike. Rode it for years–no training wheels either.  I already knew how to ride from practicing on my brothers’ throw-aways.

14. What is the most important thing?  About Christmas? Probably the spirit of giving. I love giving to those who expect nothing & want for nothing.  They’re usually the most appreciative.  Going to church & counting my blessings, not my worries.

15. What is your favorite holiday dessert?  Any kind of pie-except mincemeat–never did like its taste.

16. What is your favorite holiday tradition? Giving money cards to all the little children in my family, specifically $5 bills.  It’s what my Grandmother always gave the grandkids & great-grandkids, regardless of their age.  The cards were always placed in the tree & that’s where they’ll always find them.

17. What tops your tree? A big white star.

18. Which do you prefer, giving or receiving?  Answered that one!

19. What is your favorite Christmas song? Anything from Handel’s Messiah. I like O, Holy Night also.  There’s really quite a lot that I like.

20. Candy canes: yuck or yum? Mostly yum!  I’ve grown quite fond of the Hershey’s chocolate mint ones, but as long as the flavor isn’t too funky, they’re all good.

Here We Go Again

Last night, DH had to be taken to the ER (or ED) as he was showing all the common symptoms of dehydration. Just two days earlier, his urologist had surgically implanted a suprapubic catheter. 

A quick bio of DH: he’s been a quadriplegic for the last 27 years & has dealt with more bladder infections than I care to mention. He’s been thinking about having this procedure for years, & finally decided that now’s the time. 

The procedure went exceptionally well, he was stable & feeling very well, so he was sent home same day.  Friday, his gut was cramping, he was passing a few clots, but that was to be expected. Yesterday morning he awoke with  severe headache, & same cramps. Now mind you, his fluid intake since his discharge has been normal, he took all his meds, along with acetaminophen for the headache. Total compliance.  Headache subsided a little with the cramping , but then about every 1/2 hour or so, it would come back. These yo-yo symptoms went on for a few hours so we contacted his surgeon. All mentioned symptoms were not abnormal. Blood in urine was much lighter which was a good sign–but so was his urine output, despite that he’d been drinking fluids all day. He hollered for a bucket & right then I knew it was going to be a long night for him.  All he did was dry-heave. I took his BP & it registered 64/48.  So, back to the hospital he went, to the ED. After triage & getting a cot, he started coming back to life as the IV fluid was administered.  CT scan was done & no leakage at the surgical site, head scanned as well, all OK. We were told a bed in ICU was waiting for him so I went home feeling good about the outcome. Wrong!

I called the hospital this morning only to find out that he’d spent the night in the ED. I wasn’t worried mostly about that, because I knew he was being tended to. The staff was wonderful. My biggest fear is bedsores.  Those cots are not ideal for anyone with paralysis.  The staff member who answered the phone said they just turned him.  Well, it’s not that I don’t believe her, I just know DH better than anybody, even his own parents.  I’m sure he’s OK, I just  know he’s going to be pissed, because they told him last night a room was ready for him.  And a little about the hospital: it’s brand-new, in an area where drug-seekers & other non-emergent cases are virtually non-existant (looks more like a fancy hotel). There was barely anyone in their ED last night. So we’ll just see……..

Your Fax Machine is Not Your VCR

I have to rely heavily on our company’s fax lines, like everyone else in the healthcare industry, to do my job.  Most fax machines, if not all of them, have a time & date stamp feature that you set just like a clock. Two days ago, I received orders from a physician’s office for a scooter, along with the examination notes from the face-to-face office visit/mobility exam.  The time & date stamp at the top showed ‘ 6/20/2006  14:15 PM’.  Now for anyone who’s not aware of this, Medicare & many insurance carriers accept that stamp as the actual ‘received by’ time/date. So why is this so important?  Medicare, & the insurance companies who follow Medicare’s documentation criteria, only allots DME providers a 45-day window from the date of the face-to-face exam to receive the required documentation.  Now of course, all the documtation indicated the actual date of the order & the exam, so in this particular case, I wasn’t compelled to bother the physician’s office to update their fax machine. But doing so can prevent processing delays, & be a big difference in whether a claim is paid or not–not to mention auditing purposes. If you are aware of the problem, fix it or find someone who knows how to.  Just my OCD rearing it’s ugly head again.

Waterlogged

I wanted to insert a You Tube clip but my computer was just ‘rebuilt’  two days ago & I need to recheck all my internet settings first which will take some time since I’m not that savvy with the PC.  So instead I’ll just tell you the tale.  Two years ago: picture a young adult in a power wheelchair with all his family & friends poolside (in-ground) on a hot summer day just enjoying the weather & watching a sibling perform some diving skills off the platform. ‘Tommy’ has cerebral palsy & has maneuvered independently in a power wheelchair for years, despite a long history of severe hypertonia, joint contractures, seizures & uncontrollable arm/leg/head movements. Tommy was just thrilled to see his brother swim for the first time & was eager to be his cheering squad as his brother performed a multitude of belly-flops & cannon balls. Tommy moved closer to the platform to get a better view & mom was close by to supervise. Lo & behold, Tommy became a bit too excited, & tapped his joystick toggle just enough to drive the chair right into the pool–with him strapped in it.  The chair alone weighs well over 100 pounds so you can imagine how fast it sank with Tommy still strapped to it.  Now mind you, our rehab department didn’t hear about all this until the day after.  Mom called & the tears just spilled out over the phone.  She had jumped into the pool immediately, & was able to release Tommy & bring him to the surface & eventually out of the water. Fortunately, no one was hurt, Tommy had just a little water in his lungs. Mom told us, “if he was going to die, I was going to go with him”, & I knew she meant every word. I’m sure you can figure out what happened to the power wheelchair.  Now Tommy has funding through the State.  Our state allows replacement of such equipment every five years, unless a major change in condition occurs where different equipment is warranted or, if the current equipment is damaged due to fire, traffic accident, or stolen—you get the picture.  Mom knew she should’ve killed the power switch as Tommy got closer to the pool’s edge; she was carrying a tremendous amount of guilt.  So after much finger-pointing & investigation this is what we had: problem number one–the ‘incident’ took place at someone else’s home. Number two–mom never filed an insurance claim with the homeowner. Three–Tommy had no backup wheelchair.  Mom had dealt exclusively with us from day one so we were compelled to help her & more importantly, Tommy needed a means of primary mobility & fast.  We were able to provide a loaner, which isn’t very often, mainly because clients of this nature generally require specialized or customized seating. After finding a therapist willing to justify a new one, & fighting with the State about the chain of events, it took us just a little over 13 months to get an approval for a new chair.  I won’t even go into detail about the amount of documentation I had to gather throughout this whole mess.  Tommy got what he needed in the end & mom learned an invaluable lesson–one that I hope will never be repeated.

Hey! Keep it Clean!

Several days ago a client came into our service department (yes, we actually service much of what we sell) with a small-volume aerosol compressor, aka a nebulizer, which is used primarily to nebulize medication to treat lung diseases like COPD & asthma, as well as many others.  Anyway, the complaint was ‘that it wasn’t working’–no specifics. So it was red-bagged per protocol & taken to our service tech for a quick checkup.  Now, this is a common complaint. Aaaannnnd 99% of the time the cause is lack of patient equipment care in the home.  Sure enough, the first thing the tech checks is the input filter.  It was blacker than a charcoal briquet.  New filter installed, unit cleaned & tested, normal psi output.  The machine was brought back to the service desk & then the client’s account was accessed for activity. Turns out they haven’t bought a new mouthpiece/medicine cup since 2006. Ick.  Needless to say they were given new ones & strongly encouraged to get new ones every two weeks.  C’mon folks– medical equipment that your insurance purchases for you requires routine care & maintenance.  It takes very little effort in most cases.  Oh, & those hose thingys that hook up to your oxygen concentrator to help you breathe are NOT meant to aerate your fish tank (true story!).

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