Worst Practices

[pathstudent]

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I just reviewed a breast biopsy case. It was a high grade ductal with DCIS present and it was ER, PR negative and Ki-67 high positive.

The pathologist says that because it is ER and PR negative he did a panel of immunostains, like about ten of them to prove it was not a met to the breast. THey came back possibly supporting a GI tract primary and negative for breast ones. Then he just decides to ignore and says the morophology and clinical features are most consistent with breast cancer. GIve me a break. Who does that? If you don't care what the tests show, don't order them . That was about 1500 added to the pathology bill.

And ,what, about 30% of breast cancers are going to be poorly diff and hormone negative, so if you do this over and over you are costing taxpayers and insurance premium payers thousands and thousands of dollars.

Any other examples of worst practices.

 

[Gene_]

Automatic ordering of iron stains on aspirate smears, biopsy and particle clot. In a lot of cases, a single iron stain is not indicated. Always ordering 3...give me a break.

 

[pathstudent]

Automatic ordering of iron stains on aspirate smears, biopsy and particle clot. In a lot of cases, a single iron stain is not indicated. Always ordering 3...give me a break.

RIght Especially if the case is a staging marrow for hodgkin.

 

[Arctic Char]

I've seen flow reports from "the outside" with every damn CD marker under the sun, for patients with iron deficiency anemia. we're talking panels with >30 markers . . . unnecessary and exploitative. i don't even know what some of them are for!

 

[Ombret]

Prostate cocktail on every core. 88342 x 12.

 

[Alteran]

I saw a bone marrow biopsy in consultation where the indication was for anemia, but he had a remote history of carcinoma of unknown primary. I guess with that history the guy signing it out saw that biopsy as Carte Blanche and went nutso: he ordered every cytokeratin under the sun, S100, vimentin, PSA, PSAP, MelanA, HMB-45, and some soft tissue stains (and that's what I remember off the top of my head). He did this to prove there was no metastatic tumor in the marrow. I'm guessing the guy is color blind or something because he couldn't obviously tell by the H&E that it was NORMAL!!!!!

 

[green mantis]

I saw a bone marrow biopsy in consultation where the indication was for anemia, but he had a remote history of carcinoma of unknown primary. I guess with that history the guy signing it out saw that biopsy as Carte Blanche and went nutso: he ordered every cytokeratin under the sun, S100, vimentin, PSA, PSAP, MelanA, HMB-45, and some soft tissue stains (and that's what I remember off the top of my head). He did this to prove there was no metastatic tumor in the marrow. I'm guessing the guy is color blind or something because he couldn't obviously tell by the H&E that it was NORMAL!!!!!

The pathologist can bill for the stains, but does he necessarily get paid for interpreting all of them. I thought there was a limit for non-HP cases. I've seen some bone marrow cases from one of the large private labs that have a full page of immunostains.


----- Antony

 

[2121115]

.

 

[2121115]

I am not saying all of the above are justified; however, many of you in residency will find it much different in private practice when it comes to working up cases with no history or inadequate history. It also important to remember that in academics you can be wrong and people will chalk it up to "that must have been a hard case". In private practice you risk losing an account for being not thorough enough. It is a different ballgame.

 

[gbwillner]

The pathologist can bill for the stains, but does he necessarily get paid for interpreting all of them. I thought there was a limit for non-HP cases. I've seen some bone marrow cases from one of the large private labs that have a full page of immunostains.


----- Antony

I thought this was specific to the institution... they just stop billing after X number of immunos (for us it's like 12) per case. Also, if the IHC is not described in the report it is also not billed.

And YIKES for all the stuff posted.

 

[WEBB PINKERTON]

Get used to seeing patients billed for a lot of questionable immunos. EVERYONE does it and since accession numbers are down, its a legal way to make up the lost revenue.

Maybe you should turn the pathologist in to http://www.pathologyblawg.com

I LOVE that website. Great idea, whoever is in charge of it.

 

[Torsed]

There will be that rare melanoma met. I wouldn't knock him ordering those immunos, every expert witness that would testify against him would say "well of COURSE I would have ordered everything in the book!" Never know what was going on that day in the lab, might have been a bad day for him/her. Sometimes things that seem straight forward may not be.

And I agree, many stains are ordered to make up for lost revenue, unfortunate.

 

[malchik]

The OPs case sounds like the pathologist wanted to just sign it out as breast primary, but a clinician was pushing for met and asking for the immunos. The pathologist got the stains and then went ahead with his favored diagnosis anyway.

 

[pathstudent]

The OPs case sounds like the pathologist wanted to just sign it out as breast primary, but a clinician was pushing for met and asking for the immunos. The pathologist got the stains and then went ahead with his favored diagnosis anyway.

Totally doubt it. Pathologist is likely a young whipper snapper immuno trigger finger happy pathologist trying to be fancy and or maximizing the pathology charge. He orders a bunch of Immunos in what was an obvious idc 3 with dcis and then it backfires by staining for cdx2 ck 20 and ck7. But because he knows this is an obvious breast primary he just disregards the results.

 

[Kunu]

In the past year I had a case that the first pathologist signed out as ductal CA without a work-up. Long story short- it ended up being a squamous CA- small cell variant met to the breast from a lung or head and neck primary or something like that dont remember. It happens. Any individual case its easy to look back and then scrutinize not being in the first persons place. Its wasteful patterns that should be criticised.

 

[2121115]

Totally doubt it. Pathologist is likely a young whipper snapper immuno trigger finger happy pathologist trying to be fancy and or maximizing the pathology charge. He orders a bunch of Immunos in what was an obvious idc 3 with dcis and then it backfires by staining for cdx2 ck 20 and ck7. But because he knows this is an obvious breast primary he just disregards the results.

Actually, that is not very likely. Have you been in private practice before? Malchick's response above is FAR more likely. Clinicans call requesting specific immunos all the time. Not to mention examples like one I saw the other day where a pathology group was competing for an account and critcized the other group to the clinican based on one of their reports signed out as a metastatic carcinoma consistent with primary site X (the obvious site based on the clinical history). The competing group then told the clinican that even though the pathologist who signed out the report was right, they weren't thorough enough and it "looks like they didn't even think about other potential sites and that is dangerous. We would have worked it up more thoroughly." You don't need that getting in the heads of the clinicans sending you specimens.

 

[Thrombus]

Actually, that is not very likely. Have you been in private practice before? Malchick's response above is FAR more likely. Clinicans call requesting specific immunos all the time. Not to mention examples like one I saw the other day where a pathology group was competing for an account and critcized the other group to the clinican based on one of their reports signed out as a metastatic carcinoma consistent with primary site X (the obvious site based on the clinical history). The competing group then told the clinican that even though the pathologist who signed out the report was right, they weren't thorough enough and it "looks like they didn't even think about other potential sites and that is dangerous. We would have worked it up more thoroughly." You don't need that getting in the heads of the clinicans sending you specimens.

😱😱😱

Everything in pathology is great. Nothing to see here pathology applicants. Move right along.

 

[yaah]

Actually, that is not very likely. Have you been in private practice before? Malchick's response above is FAR more likely. Clinicans call requesting specific immunos all the time. Not to mention examples like one I saw the other day where a pathology group was competing for an account and critcized the other group to the clinican based on one of their reports signed out as a metastatic carcinoma consistent with primary site X (the obvious site based on the clinical history). The competing group then told the clinican that even though the pathologist who signed out the report was right, they weren't thorough enough and it "looks like they didn't even think about other potential sites and that is dangerous. We would have worked it up more thoroughly." You don't need that getting in the heads of the clinicans sending you specimens.

Just because clinicians call and ask doesn't mean you have to do it. If you have a good relationship with the clinician that helps, as does calling them when something may not make sense to them. I just had a case the other day with a patient who had two recent malignancies and they biopsied a third site to see which one was the problem and it was a third malignancy. So I called. I also put in the report about how the case didn't match the prior two, etc. It can be a good opportunity for education as well.

Thorough workup does not require immunostains in many cases, particularly when immunos can lead to more confusion. If you have no communication or a report that is too simple then clearly the clnician can wonder if you weren't working it up thoroughly.

We get requests all the time from clinicians to "do AFB, GMS, etc" on lung biopsies but we don't always do them. If lesional tissue is not there there is no point to do it.

That being said, you of course have to be careful that you don't go too far and reject all clincian calls/concerns. They often have information that you didn't consider or they didn't provide. So sometimes clinician communication can lead to you revising your diagnosis. But it doesn't mean they will disrespect you because of it. Unless of course you don't respect them.

 

[pathstudent]

Actually, that is not very likely. Have you been in private practice before? Malchick's response above is FAR more likely. Clinicans call requesting specific immunos all the time. Not to mention examples like one I saw the other day where a pathology group was competing for an account and critcized the other group to the clinican based on one of their reports signed out as a metastatic carcinoma consistent with primary site X (the obvious site based on the clinical history). The competing group then told the clinican that even though the pathologist who signed out the report was right, they weren't thorough enough and it "looks like they didn't even think about other potential sites and that is dangerous. We would have worked it up more thoroughly." You don't need that getting in the heads of the clinicans sending you specimens.

No way to know for sure but the report said "because the tumor is er and pr negative immunostains are peformed to exclude metastasis to the breast".

 

[2121115]

Just because clinicians call and ask doesn't mean you have to do it. If you have a good relationship with the clinician that helps, as does calling them when something may not make sense to them. I just had a case the other day with a patient who had two recent malignancies and they biopsied a third site to see which one was the problem and it was a third malignancy. So I called. I also put in the report about how the case didn't match the prior two, etc. It can be a good opportunity for education as well.

Thorough workup does not require immunostains in many cases, particularly when immunos can lead to more confusion. If you have no communication or a report that is too simple then clearly the clnician can wonder if you weren't working it up thoroughly.

We get requests all the time from clinicians to "do AFB, GMS, etc" on lung biopsies but we don't always do them. If lesional tissue is not there there is no point to do it.

That being said, you of course have to be careful that you don't go too far and reject all clincian calls/concerns. They often have information that you didn't consider or they didn't provide. So sometimes clinician communication can lead to you revising your diagnosis. But it doesn't mean they will disrespect you because of it. Unless of course you don't respect them.

I don't disagree with any of that. I was just trying to illustrate that there are reasons that things get ordered that, in hind sight or down the road, may seem odd to an academic reviewing the case, and that many times private practice groups have pressures and situations (like holding onto an account) that don't exist in academics.

 

[pathstudent]

I don't disagree with any of that. I was just trying to illustrate that there are reasons that things get ordered that, in hind sight or down the road, may seem odd to an academic reviewing the case, and that many times private practice groups have pressures and situations (like holding onto an account) that don't exist in academics.

In general running up the patient's bill for nonsense won't help hold onto the account.

 

[KCShaw]

All depends on how you market it. Just like suggested above, it's pretty easy to make a pathologist/group look bad by throwing out a few remarks here and there.

Ballooning medical costs aren't ALL about litigation. Some are about competition and marketing, too. We do more than the next guy, which is a good thing, take us to your leader! It doesn't get billed to the surgeon, and surgeons/oncologists tend to push for more anyway. Patients think about themselves and not the system as a whole, and generally don't pay either; but they generally think the same way, that more is better. Insurance companies and medicare, etc. get stuck holding the bag for the most part, and we continue our morbid little dance into oblivion with them.

 

[lipomas]

All depends on how you market it. Just like suggested above, it's pretty easy to make a pathologist/group look bad by throwing out a few remarks here and there.

Ballooning medical costs aren't ALL about litigation. Some are about competition and marketing, too. We do more than the next guy, which is a good thing, take us to your leader! It doesn't get billed to the surgeon, and surgeons/oncologists tend to push for more anyway. Patients think about themselves and not the system as a whole, and generally don't pay either; but they generally think the same way, that more is better. Insurance companies and medicare, etc. get stuck holding the bag for the most part, and we continue our morbid little dance into oblivion with them.

Yeah, unfotunately the dirty little secret is that lowering malpractice payouts or other "reforms" doesn't seem to decrease spending at all. The healh policy wonks out there are all over that data. It's hard to really get a good study on it though. But since Texas instituted all their reforms there has been no decrease in overutilization.

A lot of it is due to marketing and competition. We occasionally get cases that we know are going to get sent out for another opinion because the patient will go doctor shopping to the large academic behemoth that is close by. Sometimes we order a couple of extra stains because we KNOW that the academic behemoth will do it if we don't, and we don't want to make them look any smarter.

 

[NuckingFuts]

Yeah, unfotunately the dirty little secret is that lowering malpractice payouts or other "reforms" doesn't seem to decrease spending at all. The healh policy wonks out there are all over that data. It's hard to really get a good study on it though. But since Texas instituted all their reforms there has been no decrease in overutilization.

A lot of it is due to marketing and competition. We occasionally get cases that we know are going to get sent out for another opinion because the patient will go doctor shopping to the large academic behemoth that is close by. Sometimes we order a couple of extra stains because we KNOW that the academic behemoth will do it if we don't, and we don't want to make them look any smarter.

I'm at an "academic behemoth" and funny thing is, I see myself and colleagues ordering crap specifically for the same reason- that "experts" at other academic behemoths will order the same garbage- and as far as I can tell, THEY set the standard of care. amiright?

 

[lipomas]

I'm at an "academic behemoth" and funny thing is, I see myself and colleagues ordering crap specifically for the same reason- that "experts" at other academic behemoths will order the same garbage- and as far as I can tell, THEY set the standard of care. amiright?

Yep, there's always another expert somewhere. And experts have arguments in the literature and they sometimes fight them using consult cases as "evidence." Example 1: Thyroid lesions which may be FVPTC or may not be. Example 2: DCIS vs ADH.


Here's some bad practice for you: Shotgun flow and cytogenetics ordering on every bone marrow you get. Especially the flow. Let's order an acute panel on this case of low grade MDS vs nothing, there might be some abnormalities! Let's order flow and cytogenetics on this case of Hodgkin's lymphoma staging! Let's order plasma cell flow on this case with 60% plasma cells!

 

[NuckingFuts]

Yep, there's always another expert somewhere. And experts have arguments in the literature and they sometimes fight them using consult cases as "evidence." Example 1: Thyroid lesions which may be FVPTC or may not be. Example 2: DCIS vs ADH.


Here's some bad practice for you: Shotgun flow and cytogenetics ordering on every bone marrow you get. Especially the flow. Let's order an acute panel on this case of low grade MDS vs nothing, there might be some abnormalities! Let's order flow and cytogenetics on this case of Hodgkin's lymphoma staging! Let's order plasma cell flow on this case with 60% plasma cells!

I hear ya- and I absolutely hate it. I happened to see a case this week of a paratesticular mass. An expert at MGH called it a mesothelioma, and a couple of other giants at Indiana University called it an adenocarcinoma of the rete testis. What did I do? I called it what I thought it was- in this case the latter.

 

[yaah]

Yep, there's always another expert somewhere. And experts have arguments in the literature and they sometimes fight them using consult cases as "evidence." Example 1: Thyroid lesions which may be FVPTC or may not be. Example 2: DCIS vs ADH.


Here's some bad practice for you: Shotgun flow and cytogenetics ordering on every bone marrow you get. Especially the flow. Let's order an acute panel on this case of low grade MDS vs nothing, there might be some abnormalities! Let's order flow and cytogenetics on this case of Hodgkin's lymphoma staging! Let's order plasma cell flow on this case with 60% plasma cells!

I have heard of pathologists who essentially order flow on every peripheral smear they are asked to review. And some clinicians who order flow every 6 months to follow CLL patients.

It's strange - our clinicians basically trust us to run whatever ancillary stuff we think is necessary on marrows. Flow, cytogenetics, FISH, or nothing. But some cases we get from outside it's harder to talk the clinicians out of ordering Flow + Karyotype + MDS FISH panel on a chronic anemia r/o low grade MDS patient.

 

[pathstudent]

I have heard of pathologists who essentially order flow on every peripheral smear they are asked to review. And some clinicians who order flow every 6 months to follow CLL patients.

It's strange - our clinicians basically trust us to run whatever ancillary stuff we think is necessary on marrows. Flow, cytogenetics, FISH, or nothing. But some cases we get from outside it's harder to talk the clinicians out of ordering Flow + Karyotype + MDS FISH panel on a chronic anemia r/o low grade MDS patient.

Ordering flow on every single peripheral smear review?! That's NuckingFuts! That transcends worst practices and approaches illegalness

 

[NuckingFuts]

Ordering flow on every single peripheral smear review?! That's NuckingFuts! That transcends worst practices and approaches illegalness

I see what ya did there.

 

[yaah]

Ordering flow on every single peripheral smear review?! That's NuckingFuts! That transcends worst practices and approaches illegalness

Yeah but see for every single case you can argue that it was appropriate. That's the genius of it. Of course, if ever confronted with your practice patterns when compared to others, you would look bad. But "looking bad" is not necessarily illegal, just unethical.

 

[pathstudent]

Yeah but see for every single case you can argue that it was appropriate. That's the genius of it. Of course, if ever confronted with your practice patterns when compared to others, you would look bad. But "looking bad" is not necessarily illegal, just unethical.

Really?

If I ask you to review a smear to look for schistocytes you can argue that immunophenotyping is necessary? Or if I ask you to look for malaria or if I ask you to look at a smear because a patient has a left shifted elevated white count. Really what good would flow cytometry do for you in any of those instances. If you claim it is appropriate in any of those instances you would be a liar or unknowledgeable.

They only time flow makes sense is if a patient has acute leukemia (i.e. you look at the smear and see over 20% blasts) or if there is an obvious lymphocytosis or atypical lymphs. That's it. Even ordering it on myleoproliferatives is nonsense too.

And yes I think a pathologist self-ordering flow cytometry as part of a panel on reviewing peripheral smears could be considered illegal with regards to the CMS.

 

[Path or bust]

Really?

If I ask you to review a smear to look for schistocytes you can argue that immunophenotyping is necessary? Or if I ask you to look for malaria or if I ask you to look at a smear because a patient has a left shifted elevated white count. Really what good would flow cytometry do for you in any of those instances. If you claim it is appropriate in any of those instances you would be a liar or unknowledgeable.

They only time flow makes sense is if a patient has acute leukemia (i.e. you look at the smear and see over 20% blasts) or if there is an obvious lymphocytosis or atypical lymphs. That's it. Even ordering it on myleoproliferatives is nonsense too.

And yes I think a pathologist self-ordering flow cytometry as part of a panel on reviewing peripheral smears could be considered illegal with regards to the CMS.

Has anyone mentioned that you're very confrontational? 🙄

 

[pathstudent]

I am just saying that if there really is a group that self orders flow on every request to review peripheral smear that they are

1) not very good pathologists

And

2) trying to dummy up some charges


Although there are no cops that would come arrest these guys. Medicare does have laws against defrauding the taxpayers. I mean the cms just made it so that you have to specifically ask for an automated diff. It used to be you just got one when you ordered a CBC but they have stated that that don't fly. If getting an automated diff has to be specifically ordered by a clinician I would see the cms have issues with a pathology group that bundles flow with an 85060.

 

[yaah]

Really?

If I ask you to review a smear to look for schistocytes you can argue that immunophenotyping is necessary? Or if I ask you to look for malaria or if I ask you to look at a smear because a patient has a left shifted elevated white count. Really what good would flow cytometry do for you in any of those instances. If you claim it is appropriate in any of those instances you would be a liar or unknowledgeable.

They only time flow makes sense is if a patient has acute leukemia (i.e. you look at the smear and see over 20% blasts) or if there is an obvious lymphocytosis or atypical lymphs. That's it. Even ordering it on myleoproliferatives is nonsense too.

And yes I think a pathologist self-ordering flow cytometry as part of a panel on reviewing peripheral smears could be considered illegal with regards to the CMS.

Not saying it makes sense to me, I'm saying that if you are trying to argue the case to a non-pathologist you could sway them based on the individual case.

 

[Ombret]

At our academic behemoth I've been told that IHC is not all that profitable. We basically lose money on 88342 due to the high cost involved (chiefly reagent cost). If that is true, and if the pathologists know it, then IHC overuse no longer looks like a way to pad the bottom line--but rather a good example of either lazy or overly defensive medicine.

 

[pathstudent]

At our academic behemoth I've been told that IHC is not all that profitable. We basically lose money on 88342 due to the high cost involved (chiefly reagent cost). If that is true, and if the pathologists know it, then IHC overuse no longer looks like a way to pad the bottom line--but rather a good example of either lazy or overly defensive medicine.

YOu are talking to the wrong people.

The global on IHC is about 105 per immuno. The TC alotted for that is about 60-65. There are different prepartations and kits for the antibody depending on the particular antibody, manufacturer and stainer you using but no way should any "normal immuno" come close to costing you 60 with all expenses included.

 

[WEBB PINKERTON]

I just hope immuno reimbursement isnt cut drastically due to abuse. Urovysion was cut mostly thanks to in-office urology labs who saw it as another way to make mo money. Poor Plandowski sure was sad when urovysion reimbursement dropped. He needs to look in the mirror to see the cause for why it happened.

 

[TMZ2007]

Our hemepath department runs a lot of flows on peripheral smear reviews that we get referred to us from the community, under the guise of providing "customer service" as a "reference lab." I'd say that the majority are warranted (lymphocytosis, etc), but some of them have pretty weak/no indications, IMO. Silly question, but do you have to meet some criteria in order to get paid for flows? Are we taking a bath on these cases for the sake of "customer service"?

 

[2121115]

at our academic behemoth i've been told that ihc is not all that profitable. We basically lose money on 88342 due to the high cost involved (chiefly reagent cost). If that is true, and if the pathologists know it, then ihc overuse no longer looks like a way to pad the bottom line--but rather a good example of either lazy or overly defensive medicine.

lol.

 

[LADoc00]

Automatic ordering of iron stains on aspirate smears, biopsy and particle clot. In a lot of cases, a single iron stain is not indicated. Always ordering 3...give me a break.

FYI- I think regardless you end up with 1xFE stain charge billable. At least what CMS will pay for.

 

[LADoc00]

I just hope immuno reimbursement isnt cut drastically due to abuse. Urovysion was cut mostly thanks to in-office urology labs who saw it as another way to make mo money. Poor Plandowski sure was sad when urovysion reimbursement dropped. He needs to look in the mirror to see the cause for why it happened.

Guys: Urovysion was INSANE. I was billing ~$2K a week for literally 10 minutes of work/week putting me in the same ballpark per hour as Lebron James.

If anyone thought that was ok, you need to check yourself.