First Posted 12/20/2013
In the middle of an already-hectic schedule, my office received a call from a pharmacist at Roundy’s Pharmacy, Sheboygan WI saying that he couldn’t fill a script for oxycodone without the patient’s ICD-9 number.  The ICD-9 is soon to be replaced by ICD-10, a system that applies numbers to every medical illness under the sun.  The numbers are used for billing under Medicare, Medicaid and insurance networks.

The person at my office who answers such calls asked me about the number, and suggested that I leave it at that.  “Pick your battles” she said.  “No need to make enemies on purpose!”

She had a point… but I get frustrated as layer after layer of regulation squeezes the life out of the medical profession.  One more thing to attend to is not a huge deal; the extra 3 minutes that it takes to look up a number for each prescription will simply mean that patients have 3 fewer minutes to ask questions.  But this is just one little example of one script and one pharmacy.  Another pharmacy now requires patient diagnoses to be written on every controlled substance for Medicaid prescriptions.

The greatest frustration isn’t the rules themselves, but that individual pharmacies make up their own rules for their own reasons.  Each pharmacy cites good ideas that led to their new requirements.   But I can’t predict where each patient will fill each script, so someone is added to the office to handle these and similarly-needless calls.  In a clinic with many doctors, the extra employees really add up at some point.  And patients pay higher and higher costs, to support layer upon layer of ‘good ideas.’

I called the pharmacist and asked why he needed the code.  I’ll mention at this point that the patient, a man in his early-60’s, needs an opioid agonist for severe bilateral leg pain that forced him into early retirement.  Nobody—not myself, and not the many other docs who have consulted on his care—have been able to determine the reason for his pain, despite countless tests and imaging studies.  But I’ve known the gentleman for years, and his suffering is genuine.

The Roundy’s pharmacist said that ‘the DEA is all over us, and they require us to ask for it.’  Nice try, I thought to myself.  He was lying.  I asked him to refer me to the web site or register where the law is listed or described, explaining that I’ve never heard of such a rule.  He said that the rule isn’t ACTUALLY a DEA rule—but it probably WILL be.  He said that for now, Roundy’s has a policy that ICD-9 codes are written for any scripts for immediate-release oxycodone.

Is the rule just for oxycodone, I asked?  What about Opana, or fentanyl, or dilaudid?  ‘No—just for oxycodone’ he stated.   ‘Don’t you about the oxycodone problem out there?’

I asked, what about all of the other potent mu agonists on your shelves?  Isn’t it a bit arbitrary, requiring a code for oxycodone and not for even-stronger opioids?   He answered that he worked in Milwaukee, so he has special insight into the drug problem out there.  Oxycodone is abused ‘way out of proportion’, he explained. In fact, ‘you’re the only doctor who has ever had a problem with this.  Don’t you think we should be trying to reduce diversion?’

I asked how requiring an ICD-9 number reduces diversion.  He answered that with what is going on out there, it can’t hurt.  I asked how he knew that the number a doctor wrote on the script was accurate?  Did he have any way of checking to see if the diagnosis was correct, and not just made-up?  Did he know that people interested in obtaining opioids illicitly could use the same internet that I used to make up their own codes? He again pointed out that nobody else complains, and suggested that I have too lax an attitude toward narcotics. At this point I had to get back to my patients, so I gave him the all-important number:  338, Chronic pain. Don’t we all feel a bit safer now?

Beyond the hassle, I am surprised at how little people care about their privacy these days.  I gave the pharmacist the most general code I could, but most ICD codes are far more specific. When I asked the Roundy’s  Pharmacist if he thought it right that everyone who views the script would know a patient’s diagnosis, he acted insulted and said that HE was part of the patient’s health care too—so HE had as much ‘right’ to know the diagnosis as I did.   But it isn’t just the pharmacist; the script will be seen by other pharmacy staff that live in the same small town.  Should the person who collects the script at the Rx drop-off window know that Mr. Jones has cancer of the pancreas before he tells his family? Should the tech who transcribes prescriptions know that Mrs. Jackson has genital warts?

I read today about the lack of security of private data in the US Government’s foray into health insurance—cracks in data protection that would never be accepted from a private corporation.  But even if or when the software gets fixed, I’m amazed how few people are concerned that their diagnostic codes will be floating through the IRS, of all places.  I am amazed that the same country that elected people who passed HIPAA in 1996 would be so open with their health information with both the public and private sector.

I’m getting off-track; there are so many areas where things have changed, and I want to stick with the pharmacist, since he is the person who got me riled up earlier today.  What do readers think?  Do people know that pharmacists are demanding their diagnostic codes?  Do they care?  Are you comfortable standing in line to pay for your medication when the pharmacist says, loud enough for everyone in line to hear, ‘Oh– I see you are treated for opioid addiction!’  Do you think we will swing back to the era where healthcare data was considered intensely private?

And after viewing the attached chart—are you happy with the growing number of healthcare middle managers who add layers and layers of costs, without seeing a single patient?

I’ve had a couple comments— but for some reason the blog stuck them under the wrong post.  I’ll share them here:

Submitted on 2013/12/21 at 10:56 pm

Good Topic Dr. Junig, I personally and because I feel so strongly about my privacy, refuse to even use my company provided insurance. I pay out of pocket for my office visits and meds. I even have my Dr. write the script so the label on the bottle reads that it is taken for pain. I hate nosy people, much less government. I am neither ashamed or proud of my condition, but it is that….”MY” condition that’s most important to me. I will share it with who “I” want and that’s all. When the day comes when I am on medicare or medicaid, I guess my privacy will go out the window.

Submitted on 2013/12/25 at 7:26 pm

Had virtually the same conversation with a pharmacist at Costco, including the lie about it being required by the DEA, patient privacy, verification of the accuracy of the diagnosis and appropriate use of opioids for the condition, and how giving a pharmacist an ICD-9 code prevents misuse or diversion.  Then I realized how pointless the argument was.  Called the patient and advised that he use a different pharmacy, but the patient was without prescription coverage and desperate for the best price.  Called the pharmacist back and gave him the ICD code for lumbago.


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