And Yet More Billing

So it turns out that the anesthesia department at B&W uses a single code to stand for several different surgeries, relying on the diagnostic code to tell the insurer what is going on.

And telling the consumer/patient NOTHING AT ALL.

I mean, when you go to a fancy restaurant and pay, oh, $35 for truffled goose liver or sake-soaked squid or something, would you be happy if your check showed thaat you had a grilled cheese sandwich with a code to tell your credit card company what you really had?

Some sort of action may be in order.

Someone gets to have a bad day... not me, though!

The anesthesia bill was clearly coded wrong. The very nice customer service rep I spoke with says they will re-code it, resubmit it to the insurer, return the payment the insurer already made, and "generate a new responsibility" for me.

Query: the CSR was able to pull up my diagnosis on the computer and see that it didn't match the type of surgery for which I was billed. Why couldn't any other parts of The System do that? It shouldn't take a programming genius to restrict the list of valid codes based on the diagnostic code.

Billing.

And wouldn't you know, Bravest (the spouse) and I have both run into a bad streak of billing errors?

Bravest got told he had to pay a huge sum for a visit to the dermatologist.  Turns out, someone had written the wrong code and thought he had maxed out on his yearly visits to a chiropractor. Neither of us has a chiropractor. (The phrase "manipulative visits" was a clue.)

I had a mysterious bill from Brigham and Women's with a previous balance of Quite A Lot of Money. I had never received a bill for that amount. Turns out, it was for services on August 3rd, the pre-op visit, which is the day I updated my billing and insurance information with them -- but the change didn't move as fast through The System as the bill did, so they sent that one to a place I haven't lived in more than 15 years, and billed the wrong insurance company. (I had to tell the lady on the phone to stop interrupting me and stop calling me "hon", too.)

And then I went to pay the anesthesia bill today -- same hospital, different department -- and it says I had shoulder surgery. Someone entered the wrong code. So there's another energy-draining phone call.

While we're on the subject, I fully expect to receive at least eight separate bills from Brigham & Women's, and probably more, to whit:

1. Lab work.
2. Pathology.
3. Radiology.
4. Nuclear medicine (yes, they are separate.)
5. Surgery.
6. Anesthesia.
7. Postoperative care.
8. Any doctor who so much as glanced in my direction.

This expectation is based on our experience with Bravest's various hospitalizations and surgeries. The separate billing (to separate addresses, with separate numbers to call if you have questions) is an historical artifact dating from the days when radiologists, anesthetists, and surgeons were all considered to be in separate practices so their payments had to be managed in separate piles of money. Now, it's just because it's too damned expensive to rationalize the computer systems.

But God protect the poor people who aren't technically sophisticated and don't understand, for instance, the difference between an EOB and a bill. It's hellishly confusing for me and my husband, and we are reasonably astute consumers of medicine.

And then there are the ER bills...

Anxiety anxiety.

So compazine is an anti-psychotic. I'm not too worried about it, as it's anti-nausea propreties are also well known. It makes you hella sleepy, but that's all to the good, really.

No, the one I'm worried about, ironically, is the ativan. Also know as lorazepam, it doesn't really do anything for nausea. It makes you forget that you were nauseated,or that you were worries about it.

I have a bad history with such drugs. Back when I was young, poor, and a new mommy, a doctor gave me a similar drug to treat back spasms. (And probably also because he thought I was anxious. I was, but for entirely justifiable reasons. We will save the rant about not drugging people who are responding normally to bad situations for another time.)

It took two days on Valium for me to start talking about suicide, a development that surprised even me. It is an experience I'd very much like to not repeat, and thinking abut it is making me feel anxious and slightly nauseated.

Which is funny, in a sick way. I plan to talk to the doctors about it.

(Please note that I may be nauseated, but I hope never to be nauseous. If I am, pipe up and say something. Maybe I can take a breath mint or hide under the blankets or something.)

And now for some Science!

Today we went in to see the surgeon's Nurse Practitioner. We were also supposed to see the surgeon, but our 11:30 AM appointment didn't happen until 1:10 PM, by which time the surgeon was already slicing and dicing over at the hospital.

The NP did check out the embroidery, and is very pleased with how fast I'm healing. She then reviewed the pathology report with me in detail, and gave me my very own copy. It's a little weird reading about the various shavings and slicing, but whatever.

Did you know that the scientific name for the type of cancer I had is the same as the name for a pimple? Neither did I! That name is comedo. On your face, a blackhead is an "open comedo" and a whitehead is a "closed comedo". In the breast, a comedo is a center of dead cells surrounded by a hungrily expanding and wildly proliferating set of cancerous cells. If they are at the surface, comedo cancers can be "squeezed". Yes, just like your momma told you not to do. (It doesn't make them go away, though.)

They are also a lot more aggressive than other sorts of cancers. Mine was very, very different from normal breast tissue, and was really growing very fast (lots of nuclei). So glad that Lump is gone!

The NP said not to worry about the little bits in the lymph vessels. If there's anything at all (and chances are good that there isn't) left behind by the surgery, the radiation and chemo will clear it. But it makes it even more clear as to why I need all this heavy-duty poison medicine.

(And they not only didn't have my medication list right, they didn't have the new medications the oncologist ordered on the list. I got a bit upset. The NP had the right list, thank goodness! and promised to make sure whateveritis is fixed before the 12th. If they don't get it right, I will refuse treatment, because I have to be sure that the people mixing the chemo know what else I'm taking. In fact, I may call the oncologist's office the week prior, just to be sure.)

Now then:

• The chemo is AC (Adriamycin/Cytoxin). The A keeps cells from making or repairing DNA. It really is a poison; fortunately, since cancer cells are madly dividing, it hits them harder than the more leisurely normal cells. The C keeps cancer cells from replicating. So, they can't reproduce and they can't repair themselves and they die. Hopefully, before anything else important dies, like my heart muscle or all my T cells.
• I will be getting Neulasta the day after surgery. This will help my blood recover its ability to fight infection sooner, so I can go through the speeded-up regimen.
• The backbone of the anti-nausea regimen is three drugs: emend, aloxi, and decadron, mostly administered with the chemo. I will also have compazine and ativan as needed, and Zofran if the nausea lasts more than three days. I have been instructed to take an ativan before coming in for my first treatment.

(This last bullet is mostly for my Uncle Bob, an expert on nausea in all its aspects, who instructed me to ask the doctor for medication to take before having the first treatment. Seems that if you take an anti-nausea medication before treatment, thus keeping you from having anticipatory nausea, you may not have much trouble from nausea at all.)

Today's extended wait was enlivened by a lady who moved from commenting on my knitting to a broad-ranging conversation that included a dig at immigrants! I jumped on that one tout de suite, but in a nice way, bringing in my great-grandparents, grandparents, and parents. She was relieved, I think, that I left her a graceful way to backtrack. Normally, I would be less polite, but the lady had to have a surprise mastectomy just a couple of weeks ago, so why point out that her doctor and mine rejoices in the last name of "Zabrinski-Calvillo"?

A long day, and a lot to digest (doing the math)

We met with the oncologist today. It was a long session, and some of it I need my notes for. For example, she obligingly outlined the whole anti-nausea regimen, which I cannot remember off the top of my weary head.

But here's the basics:

• The tumor was 1.1 cm. The margins were clear, though one was kind of close, due to the position of the tumor at the back of the breast.
• The two sentinal lymph nodes were clear.
• HOWEVER, there was some sign of Lymphatic Vessel Carcinoma, meaning that cancer cells had started to leave the tumor and were moving into the lymph system within the breast.

I am kind of freaked out a bit by the last item, but it didn't seem to concern the oncologist at all. So I am tamping down on the freaking, or trying to.

I was then presented with a number of choices, which I am not going to discuss in detail. Instead I will outline what I'm going to do. Which is:

1. Start chemo on September 12th, and have chemo every other week for four weeks.
2. Have a shot of a blood-stimulating drug the day after chemo that will speed up my recovery.

The more usual course would be to have the chemo every three weeks, but the oncologist thinks that 1) I am a fine candidate for this faster method, and 2) based on the usual schedule for radiation following chemo, I could be all done by early January. Whoo-hoo!

Now, the math. I am putting this here because several people have asked me, "Do you HAVE to do chemo/radiation?

The answer is yes, and here's why:

• If I do nothing, the chance that the cancer will metastesize somewhere else in my body, like my brain, is about 15%. Chemo will half that, down to 7.5%. Or, to put it another way, it will increase my chances of NOT having metasteses from 85% to 92.5%.
• If I do nothing, the chance of cancer recurring in the same breast is about 25%. Having radiation drops this to 10%. Or, a 90% chance of not needing a mastectomy in the future.

I hope that's clear to all and sundry, including me.

There's a bunch of logistics I have to clear, including making sure I can get the blood-boosting drug. And this fast chemo regimen is really going to wipe me out, energy-wise. I may just crawl into my hole and not come out for two months.

Oh, and it seems that the loss of hair is VERY predictable. If I start chemo on 9/12, my hair will fall out on 9/30.

More on the drug names and such in our next.

Oh, and there was a definite Boob Wars moment. As we were ushered into the exam room, our usherette handed my a clipboard with a "List of your medications, please confirm them," on it. IT WAS COMPLETELY WRONG. All that was there were the two post-surgery prescriptions (neither of which I need any more) and an asthma inhaler as prescribed by the folks in the ER two weeks ago.

I have given them the extensive list of my medications three times now. And I sat there and watched the pre-op nurse type them in, from a printout given to me directly by my PCP.

I'm feeling pretty mellow towards Dana-Farber at the moment, but if this happens again  there will be hell to pay. Or maybe just heck, if I'm feeling merciful.

And another waiting cycle ensues

I have an appointment with the oncologist Monday to discuss when to start chemo, what sort to use, and what the schedule will be. And I have an appointment Tuesday with the surgeon so she can admire her embroidery. :)

Also, a dentist appointment the following Monday so I can get one filling taken care of and go into chemo without any mouth issues.

Church today was rather strange. I got into a long discussion with a woman whose niece (only 32!) is dealing with really bad breast cancer, much worse than what's happening to me. She (the niece) apparently has a rare anomaly on the BRCA1 gene, and my even-Christian (Blessed Julian of Norwich's name for fellow-believers) was trying to extrapolate from my experience to her niece's. Despite my repeated warnings. She didn't want to question her sister (the young lady's mother), who is having a very difficult time with things, or her niece (who sounds, from her description, as though she wouldn't mind at all, but I forebore to say so because it's not my family). So, she asked me. This got us into the link between various cancers and ethnic background, and why X was happening to me while Y was happening to her niece.

It's really amazing how individualized cancer therapy has gotten.

Other than that, there's only a lot of trying to live while waiting to report. I will let y'all know as soon as I can about what the chemo schedule looks like.

In return, may I ask one favor? All sorts of chemo have side effects, and I'm sure my doctors will tell me what I need to know about them. Please, therefore, do not post links for me to read about this type or that type. I am staying away from the Internet as much as I can while dealing with this thing, because I am NOT a scientist or a doctor, and I DON'T have a way to filter claims and counter-claims, and a lot of the stuff out there is just scary and depressing. I find I scare rather easily (see previous lymphadema episode), so it's best to just try and understand what the docs are telling me.