Did not like the Doctors orders about Smoking Cigars

[toledo1969]

So 3 weeks ago I had my appendix operation, I was lucky it did not burst. So I have been without smoking Habanos now for all this time. Resting and eating well. But our Vice is just to much, my mouth waters every time I see people post their Cuban Cigar Collection. Also since there is not much I can do, I have been buying cigars on 24:24 on a daily basis. 

Now my dilema is that my Doctor is one of those "Smoking will Kill you and Cigars are 100 times worse than cigarettes" So when I asked him when I can start smoking Cigars again, he said never, They are very bad for you and they will irritate your stomach. 

I was figuring 1 month before I start with the first Habano, start with a Petit Corona, little by little. Don't over do it. Since I only have 1 vice and that is Smoking Habanos. 

[smokum]

Got that news many years ago. Layed off for a long time. Turned 60. Back at it. If its not that it will be something else. I secretly think doctors go home and stuff their faces with beef, drink whiskey , smoke weed and cigars. 

[SCgarman]

16 minutes ago, smokum said:

Got that news many years ago. Layed off for a long time. Turned 60. Back at it. If its not that it will be something else. I secretly think doctors go home and stuff their faces with beef, drink whiskey , smoke weed and cigars. 

X2. Cigars in moderation are not harmful. Doctors should not act sanctimonious. Pretty sure they have their "hobbies" also. We are all adults here, not little children.

[El Presidente]

Doctors are doctors. 

I would be concerned with a doctor who said to go out and "party like it's 1999?"

[Shelby07]

In my opinion, FWIW, i know my own body and how things affect me more than my doctor does. 

I’m not saying I ignore my doctor’s advice; if he has a reasonable explanation for what he is saying as it applies to me or my condition then I will listen to him and consider it. But if I think he’s just handing me a canned line, then I take that into account too.

 

[stevo]

Irritate your stomach? Can’t see why a cigar would have any bearing on an appendix op. And your appendix definitely isn’t your stomach.

[srbbones]

I am a cancer doctor (radiation oncologist) who smokes cigars.  I can tell you that most doctors just lump cigars in with cigarettes.  The American Cancer Society (and others) just wants to stop all smoking.  They don't want to deal with nuance, as they assume the public is unsophisticated, and needs to be treated like children.  Over my 20 plus years, I have seen hundreds of cigarette related cancers.  I have, perhaps, seen 1-2 oral cancers that might have been related to cigars.  This would be in the fellows who smoke MANY cigars per day, essentially every day.  As for the "irritation of the stomach" comment.  Maybe he is referring to relaxation of the lower esophageal sphincter that can occur with smoking.  This could cause acid reflux.  If you get heartburn after smoking, take a zantac. Has nothing to do with the appendix for goodness sake.

[Bri Fi]

1 hour ago, El Presidente said:

Doctors are doctors. 

I would be concerned with a doctor who said to go out and "party like it's 1999?"

I was in fifth grade in 1999 so that would consist of me eating cupcakes and ice cream. Pretty wild. 

[MD Puffer]

He/she may be an anti-tobacco zealot.  No doubt.  There isn't a shortage of them.

However, just at likely, if not more so, is about coding and billing.  Have you ever noticed that when you go to your primary physician- even for a specific complaint (eg., a gouty big toe), that you're asked a lengthy list of screening questions?  I came here for a gouty big toe and you're asking me about depression?  What gives?  The reason is not to be "holistic"- if anything, that would be a consequence.  The reason is that I want to be able to code as many diagnoses as possible for every visit.  There are different levels of "medical complexity".  Obviously, the higher the level of complexity, the greater the reimbursement is.  

Low complexity reimbursement rates are mediocre.  Reimbursement rates from high medical complexity codes are very nice- but a lot of high medical complexity codes is a red flag for an audit.  Your bread an butter is the medium medical complexity code- and lots of them.  There are two primary paths to meeting the billing criteria for a medium medical complexity code.  First, you can take a single complaint- either acute or chronic- and document 4 of 8 "bullets" in your HPI (the patient's subjective report of the their chief complaint- it throbs,  it's swollen, it's been this way for a month, it's getting worse, an ice pack makes it better, etc).  The simpler way is to document three chronic issues/illnesses/disorders and document their status.  That's the way to go.  So for instance...  Let's say I'm seeing an established patient for anxiety.  That's the only thing I'm treating them for- just anxiety.  Let's say they're stable and don't require any changes in their treatment.  I can document the status of that one issue (anxiety) and nothing else, and bill out at a low medical complexity code.  

But I look at this guy's chart and see that he used to have an issue with alcohol dependence.  So I ask him if he's engaged in any interval patterns of abusive alcohol consumption.  He says no.  There's a code for alcoholism in remission.  That's two down one to go.  I smell cigarette smoke.  I ask him about it.  He doesn't want to quit.  I document it.  There's a code for uncomplicated nicotine dependence, cigarettes.  That's three.  Quick and easy.  The doc who bills out at the low complexity code makes $25-40 less for that one encounter vs. the doc that asked the additional two questions.  Two questions which are asked about and documented in 1-2 minutes. 

$25-40 x 20 patients per day = $500-800 per day additional for the inquisitive doc.  You can't really extrapolate that annually because most physicians take off a large number of days per year (I took off 55 days in 2017 but I haven't counted up how many days last year).  

As a psychiatrist- it's easy for me to bill out encounters at the medium level of medical complexity because there's a large degree of psychiatric comorbidity (ie., depressed people are often anxious, or have insomnia, or smoke, or drink excessively, etc).  It's harder for primary physicians.  And that's one of the main reasons why they have to see 25-30 (or more) patients per day when I only have to see half that number.

Having written all of this, let me say I don't particularly care for this system, but it is the least bad option for providing health care.  It's basically a game.  There are rules.  The insurances companies perform random audits and the consequence for breaking the rules is that they take money back.  Not just what you might've been overpaid- you miss out on the billing opportunity altogether.  In other words if you upcharge and they find it in an audit they take back the entire amount- not just the difference between what was paid and what should've been paid.  And if you have a pattern of upcharging, well, that's insurance fraud and you go to jail.  Learning the rules allows you to optimize your earnings.  Learning to code right is part of the rules.  The difference in earnings potential between a physician who codes well and one who doesn't is staggering- as in six figures per year difference.  Same specialty, same patient volume.  And this whole concept of "complexity" has little to do with the required "criteria" for the billing codes- some suit in a boardroom (or failed clinician) came up with that idea.  I've had patients whose problems require a lot because of other medical issues or other medications but can only bill out at a low medical complexity and vice versa.

Sometimes that third billing code just falls in your lap.  Last week I had a patient I treat for ADHD.  Also has a hx of recurrent depression.  Both stable.  Couldn't figure out any other codes for him.  Didn't smoke, drank in moderation, etc.  Then he asks for something for his "nerves" because he hates flying and has a business trip in a few weeks.  Why, that's "fear of flying" and is the third ICD code I was looking for.  

 

So, your surgeon or internist could've been an anti-tobacco zealot.  Or he/she could've just been ensuring that they can legitimately submit the highest bill possible to the insurance company.  

 

 

 

[Ken Gargett]

6 hours ago, toledo1969 said:

So 3 weeks ago I had my appendix operation, I was lucky it did not burst. So I have been without smoking Habanos now for all this time. Resting and eating well. But our Vice is just to much, my mouth waters every time I see people post their Cuban Cigar Collection. Also since there is not much I can do, I have been buying cigars on 24:24 on a daily basis. 

Now my dilema is that my Doctor is one of those "Smoking will Kill you and Cigars are 100 times worse than cigarettes" So when I asked him when I can start smoking Cigars again, he said never, They are very bad for you and they will irritate your stomach. 

I was figuring 1 month before I start with the first Habano, start with a Petit Corona, little by little. Don't over do it. Since I only have 1 vice and that is Smoking Habanos. 

as someone who did cop a burst appendix and peritonitis and gangrene (may montreal sink into the sea without a trace and take its imbeciles with supposed medical degrees with it - and before i get the usual, i was told by one specialist in toronto, after i had fled the completely wrong diagnosis and was left with less than 24 hours to live had they not got to me outside montreal, that if i had any further issues, go immediately to the nearest hospital, unless i was in montreal/ottawa etc, in which case go immediately to an airport and then go to a doctor), you were fortunate. 

sadly, my fave doc has retired but i was sent to him a decade or so ago, bit longer, as i'd had clots from flying too much. he was brilliant and incredibly thorough. he was some sort of specialist GP, though never quite worked out what exactly. i do know that he was the doc that all the other doctors went to. 

first, very long interview and inspection, went through everything. did i smoke? - never cigarettes but an occasional cigar. do you enjoy it? yes. then don't stop. what vitamins etc etc do i take? listed a few. his advice? go home and put them in the bin and spend the difference on better red wine. 

best doctor ever. 

[CaptainQuintero]

  Zero medical qualifications but I know that nicotine can inhibit the healing process and cause complications.

[Toast & Taste]

2 hours ago, El Presidente said:

Doctors are doctors. 

I would be concerned with a doctor who said to go out and "party like it's 1999?"

You don't know my doctor 

Big Al 

[BarryVT]

7 hours ago, toledo1969 said:

So 3 weeks ago I had my appendix operation, I was lucky it did not burst. So I have been without smoking Habanos now for all this time. Resting and eating well. But our Vice is just to much, my mouth waters every time I see people post their Cuban Cigar Collection. Also since there is not much I can do, I have been buying cigars on 24:24 on a daily basis. 

Now my dilema is that my Doctor is one of those "Smoking will Kill you and Cigars are 100 times worse than cigarettes" So when I asked him when I can start smoking Cigars again, he said never, They are very bad for you and they will irritate your stomach. 

I was figuring 1 month before I start with the first Habano, start with a Petit Corona, little by little. Don't over do it. Since I only have 1 vice and that is Smoking Habanos. 

Based on his recommendation, I'm guessing your doctor is not an FOH member, so we wont be hearing from him! Lol

[In-A-Gadda-Davidoff]

I can empathize.  I'm currently abstaining from nicotine following my neck surgery, so I feel your pain.

 

[Bagman]

1 hour ago, MD Puffer said:

He/she may be an anti-tobacco zealot.  No doubt.  There isn't a shortage of them.

However, just at likely, if not more so, is about coding and billing.  Have you ever noticed that when you go to your primary physician- even for a specific complaint (eg., a gouty big toe), that you're asked a lengthy list of screening questions?  I came here for a gouty big toe and you're asking me about depression?  What gives?  The reason is not to be "holistic"- if anything, that would be a consequence.  The reason is that I want to be able to code as many diagnoses as possible for every visit.  There are different levels of "medical complexity".  Obviously, the higher the level of complexity, the greater the reimbursement is.  

Low complexity reimbursement rates are mediocre.  Reimbursement rates from high medical complexity codes are very nice- but a lot of high medical complexity codes is a red flag for an audit.  Your bread an butter is the medium medical complexity code- and lots of them.  There are two primary paths to meeting the billing criteria for a medium medical complexity code.  First, you can take a single complaint- either acute or chronic- and document 4 of 8 "bullets" in your HPI (the patient's subjective report of the their chief complaint- it throbs,  it's swollen, it's been this way for a month, it's getting worse, an ice pack makes it better, etc).  The simpler way is to document three chronic issues/illnesses/disorders and document their status.  That's the way to go.  So for instance...  Let's say I'm seeing an established patient for anxiety.  That's the only thing I'm treating them for- just anxiety.  Let's say they're stable and don't require any changes in their treatment.  I can document the status of that one issue (anxiety) and nothing else, and bill out at a low medical complexity code.  

But I look at this guy's chart and see that he used to have an issue with alcohol dependence.  So I ask him if he's engaged in any interval patterns of abusive alcohol consumption.  He says no.  There's a code for alcoholism in remission.  That's two down one to go.  I smell cigarette smoke.  I ask him about it.  He doesn't want to quit.  I document it.  There's a code for uncomplicated nicotine dependence, cigarettes.  That's three.  Quick and easy.  The doc who bills out at the low complexity code makes $25-40 less for that one encounter vs. the doc that asked the additional two questions.  Two questions which are asked about and documented in 1-2 minutes. 

$25-40 x 20 patients per day = $500-800 per day additional for the inquisitive doc.  You can't really extrapolate that annually because most physicians take off a large number of days per year (I took off 55 days in 2017 but I haven't counted up how many days last year).  

As a psychiatrist- it's easy for me to bill out encounters at the medium level of medical complexity because there's a large degree of psychiatric comorbidity (ie., depressed people are often anxious, or have insomnia, or smoke, or drink excessively, etc).  It's harder for primary physicians.  And that's one of the main reasons why they have to see 25-30 (or more) patients per day when I only have to see half that number.

Having written all of this, let me say I don't particularly care for this system, but it is the least bad option for providing health care.  It's basically a game.  There are rules.  The insurances companies perform random audits and the consequence for breaking the rules is that they take money back.  Not just what you might've been overpaid- you miss out on the billing opportunity altogether.  In other words if you upcharge and they find it in an audit they take back the entire amount- not just the difference between what was paid and what should've been paid.  And if you have a pattern of upcharging, well, that's insurance fraud and you go to jail.  Learning the rules allows you to optimize your earnings.  Learning to code right is part of the rules.  The difference in earnings potential between a physician who codes well and one who doesn't is staggering- as in six figures per year difference.  Same specialty, same patient volume.  And this whole concept of "complexity" has little to do with the required "criteria" for the billing codes- some suit in a boardroom (or failed clinician) came up with that idea.  I've had patients whose problems require a lot because of other medical issues or other medications but can only bill out at a low medical complexity and vice versa.

Sometimes that third billing code just falls in your lap.  Last week I had a patient I treat for ADHD.  Also has a hx of recurrent depression.  Both stable.  Couldn't figure out any other codes for him.  Didn't smoke, drank in moderation, etc.  Then he asks for something for his "nerves" because he hates flying and has a business trip in a few weeks.  Why, that's "fear of flying" and is the third ICD code I was looking for.  

 

So, your surgeon or internist could've been an anti-tobacco zealot.  Or he/she could've just been ensuring that they can legitimately submit the highest bill possible to the insurance company.  

 

 

 

Not true.  Providers bill cpt codes.  They are paid ONLY on what they do.  Complexity (ICD10) has ZERO impact on reimbursement for providers.  If you are a hospital, and you bill DRG's, then complexity does come into play.  But that is only if you go inpatient.  All outpatient/ER services are procedure level driven.   But even then, the diagnosis would have to be high enough to alter the DRG. Coming in for knee surgery (MS469) will pay the same regardless if the member is depressed or not.   The only people who truly get paid for diagnosis codes are helathplans that are risk driven.  Medicaid/Medicare.  With higher DX codes, their RAF score increases.  By increasing RAF, the government pays more to health insurance to cover the member.   The provider gets none of that money.  Unless the member truly has a condition and they need to seek more services.  Volume of CPT codes. 

99% of people will have no idea what I just said.

[TBird55]

Find a new Doctor. Three years ago I was diagnosed with Renal Cell  Carcinoma (kidney cancer). Had a successful partial nephrectomy, and Doctor said he was able to get all of it. Cancer free, still have scans every 6 months. Anyway, talked with Dr., and he has no issue with me smoking cigars. Found out he enjoys CC, so every appointment he gets 3 or 4 cigars, and a box at Christmas. The least I  can do for someone who had my life literally in his hands.

[Ken Gargett]

1 minute ago, TBird55 said:

Find a new Doctor. Three years ago I was diagnosed with Renal Cell  Carcinoma (kidney cancer). Had a successful partial nephrectomy, and Doctor said he was able to get all of it. Cancer free, still have scans every 6 months. Anyway, talked with Dr., and he has no issue with me smoking cigars. Found out he enjoys CC, so every appointment he gets 3 or 4 cigars, and a box at Christmas. The least I  can do for someone who had my life literally in his hands.

yep. mine didn't smoke cigars but he always got a good red for christmas. 

[MD Puffer]

1 hour ago, Monterey said:

99% of people will have no idea what I just said.

I tried to keep what I was writing simplified to avoid that.

With the 1997 CPT revision, code complexity is based (in part) on "at least three chronic or inactive conditions"- which have corresponding ICD codes.  Specifically, the 3+ chronic conditions allows you to quickly and easily change your HPI from "brief" to "expanded".  That's really the key to the moderate complexity code.  A complete ROS and complete history should always be obtained b/c that info can be documented by ancillary staff.  The detailed physical exam is only 6 organ systems or 12 bullets of 2 organ systems (for me as a psychiatrist I only have to perform a mental status exam with 9 bulleted elements).   For anyone wondering, I'm basically laying out the rules of the game to be able to bill out a sweet spot billing code- one that balances payment with low risk of audits. 

Yes, you're correct.  "Providers bill cpt codes."  My point is that the moderate level complexity CPT code can be based on the number of conditions addressed. My E&M billing codes are based on CMS criteria and they directly relate to complexity- for outpatient services.  When I worked inpatient it was the same except the E&M codes were different for inpt vs outpt.  Hospital employed, group employed, and private practice docs all have different reimbursement methods (the most former involve RVUs which are a foreign concept to me since I'm a fee-for-service private practitioner).  The moderate complexity medical decision making code (99214) is based on a tree of criteria.  The simplest way to create the flow chart of criterion for that tree is to pump up your HPI to an extended HPI.  That is easily done by addressing "at least three chronic or inactive conditions".  The way to do that is to know your patient's history and ask about conditions/problems that aren't even the reason they came to visit you for.  And it's why complexity is based on the ICD codes- in part.  As I said, the other components are gimmes.  I don't deal with DRGs- I submit billing codes AND the ICD diagnostic codes electronically.  First through a claims scrubber, then to the clearing house, and remittance is paid to me usually within 14 days.  My billing is in-house and I've survived a couple of desk audits so I'm pretty sure this is working for me. 

However, it may be a different story for inpt docs (though again, when I rounded on inpts the criteria were less strict and the CPT codes were different but the approach was fundamentally the same).    

But it doesn't change my point which was that it's commonplace to address as many diagnoses that you possibly can because it helps you code at a higher level of billing.

And I hear what you've saying about volume of CPT codes but that actually hurts me since I utilize additional time-based addon codes. 

But I always strive to document 3+ conditions because once I do I can forget about HPI bullets.

[Outdoorguy84]

I just posted a quick video on the front page of the forum. Show your doctor this video as I did, lmao... 

[cigcars]

     ** Remember George Burns, who lived to be 100; he smoked 20 cigars a day - El Productos! People kept asking him what does his doctors say? And George had to reply, "The doctors are dead."

[Capt. Corona]

My take on doctors and surgeons.  They are a necessary ingredient to longevity but have no business telling us how to live our lives.

It's their job to find something wrong with you and keep you in the office on a regular basis.  How else they gonna pay for all the fancy stuff they have and lay around the pool on their days off smoking Sig VI and Behikes.  

[ac031898]

3 hours ago, BarryVT said:

Based on his recommendation, I'm guessing your doctor is not an FOH member, so we wont be hearing from him! Lol

or he IS an FOH member and is after those damned QDO 54s and trying to keep 1 more person out of the running!!

[PapaDisco]

7 hours ago, srbbones said:

I am a cancer doctor (radiation oncologist) who smokes cigars.  I can tell you that most doctors just lump cigars in with cigarettes.  The American Cancer Society (and others) just wants to stop all smoking.  They don't want to deal with nuance, as they assume the public is unsophisticated, and needs to be treated like children.  Over my 20 plus years, I have seen hundreds of cigarette related cancers.  I have, perhaps, seen 1-2 oral cancers that might have been related to cigars.  This would be in the fellows who smoke MANY cigars per day, essentially every day.  As for the "irritation of the stomach" comment.  Maybe he is referring to relaxation of the lower esophageal sphincter that can occur with smoking.  This could cause acid reflux.  If you get heartburn after smoking, take a zantac. Has nothing to do with the appendix for goodness sake.

Smoke is an irritant, but a mostly non-fatal one.  However anti-anything campaigns can't handle nuance as srbbones said.  The mortality data in the Surgeon General's report is particularly surprising on this.  You've all heard me quote the part about "moderate cigar smokers" (defined as 5 or fewer cigars per day) having the same, or slightly less, mortality than non-smokers.  Pipe users were similar.  However the cigarette data was particularly illustrative of the good doctor's argument:  someone who started smoking cigarettes before age 15 and who smoked 2 or more packs per day had a mortality 3.7 times higher than normal (IIRC), BUT, someone who started smoking cigarettes at age 30 and smoked a pack or less per day had about the same mortality as a non-smoker.  Clearly one stat (the 3.7 times) became the rally cry whereas all the others were ignored.

[Connoisseur Kim]

If doctors are going to say quit puffing cigars, I will definitely say:

• "If I had taken my doctor's advice and quit smoking when he advised me to, I wouldn't have lived to go to his funeral."
  —George Burns

Honestly, there are more harmful things like fine dust (can damage person's breathing ability severely) than cigars in my opinion...

[Puros Y Vino]

I had a couple of encounters that make me think that not all doctors lump cigarettes and cigars into the same category. One particular case two summers ago. I was feeling crappy one day. My wife and I were out for a walk, I felt weak and tired all of a sudden.  I rushed to the hospital and the doctor hit me up with lifestyle questions, diet, alcohol intake and the inevitable "are you a smoker?".  I hesitated briefly, thinking I could leave this info out, but I came to my senses and fessed up.  I answered "yes, but cigars, not cigarettes. If I were to average it out over a year it'd be 1-3 cigars per week". (this is accurate for me) He sighed and kinda brushed it off.  And to paraphrase.  "That's fine, they're not exactly the same thing".  I've heard that opinion a few more times casually from nurses, doctors and the odd dentist.  This is all anecdotal of course and I don't want to delude myself. But I do find it interesting and refreshing when medical professionals don't toe the party line and lump all tobacco smoking together.  Nice to see them focus on stats, facts and details vs taking a philosophical side.