I was working down in Tucson, Arizona and our team decided to stay at a beautiful resort out in the desert. I had to be up early the next morning and ready to go by 6 am. (Those of you who know me know that I am not a morning person.) Anyway, when I got out of the shower that first morning, I noticed a large red area on my back above my left shoulder blade and in the center was a small blister. I figured I had been bit by something. But I had meetings the next two days and forgot all about it.
When I returned home that weekend, my husband commented that I had a black spot on my back. Over the next couple of days, it grew larger. I traveled to California that next week for work and while there noticed it was getting even larger and that now I had an enlarging hole in that area. When I returned home that Thursday, I saw my doctor who told me that I had likely been bit by a brown recluse, gave me heavy duty antibiotics and told me that if the hole got any larger to go to the nearest ER regardless of what city I was in, that I could lose part of my shoulder. After 9 weeks of chills and sweats, the hole slowly closed.
Fast forward about 2 months. I started noticing discomfort in my left breast and fullness under my left arm so went to my primary care doctor who ordered a diagnostic mammogram which was abnormal and an ultrasound which was also abnormal. An elderly radiologist came into the room after the tech and redid the ultrasound of the lymph nodes. She asked me if I had been ill or if anything strange had happened to me recently and I told her about the brown recluse bite on my left back. So I was scheduled for a stereotactic breast biopsy and needle biopsies of 4 lymph nodes, tons of fun. The good news is that the excisional breast biopsy showed normal tissue. The interesting thing, however, was the lymph nodes showed reactive lymph hyperplasia. I was told that I could live with my lymph nodes enlarged, that they would likely remain enlarged, that if I wanted them removed, they would do that. I chose to keep them, thank you. I had had enough of a scare – first the spider bite, and then this.
So, here’s the coding dilemma:
First visit to radiology: The diagnostic bilateral mammogram was for left breast pain and the ultrasound of the left axillary lymph nodes was for the fullness under my left arm, history of a venomous spider bite. One was covered by my regular health insurance; the other was covered by Workers Compensation.
Second visit to radiology: The stereotactic breast biopsy was for an abnormal mammogram and the needle biopsies of the left axillary lymph nodes were for an abnormal ultrasound. One was covered by my regular health insurance; the other was covered by Workers Compensation.
Question for the group: how would you code this Real Life Scenario? It took over a year for the insurance companies to subrogate this one. For the first 6 months, the health insurer wanted the Workers Compensation company to pay and the Workers Compensation company wanted the health insurer to pay. Finally the Workers Compensation company conceded that the claim was legitimate and paid for their portion. The regular health insurer paid on their portion. Then the Workers Compensation company contacted the resort, reported the brown recluse infestation in the hotel room, and the hotel paid the Workers Comp company back.
Note: Actually, the desert recluse, often mistakenly called the brown recluse, is indigenous to the Tucson area. If you travel there, check your sheets. I still travel there today but check my sheets everywhere, every time now, no matter where I travel.
