Blog — Notes of a Plastic Surgeon

Welcome to my blog. I am a plastic surgeon in Seattle and have been in private practice since 1991. I've seen more than a few interesting faces and cases through my years spent in the exam room, the operating room and the emergency room. And I have an opinion on just about everything relating to plastic surgery (and a lot of unrelated stuff). If you like my blog, let me know. Thanks for reading! Lisa

Category: Financial Issues

ICD-10. It’s heeeeeeeere.

October 1st, 2015 — 10:30am
Don't worry Barbie. There's an IDC-10 for that squirrel encounter!

Don’t worry Barbie. There’s an IDC-10 for that squirrel encounter!

Today, October 1, 2015, is the day that doctors have to switch from ICD-9 to ICD-10 diagnosis codes.  Up until today, we doctors had to rely on a mere 18,000 ICD-9 codes to describe patient diagnoses.  Doctors rely on these mandatory codes for reimbursement from insurance companies.  Years ago, when I was doing a lot of insurance work, I had many of these codes memorized.  A couple of examples of ICD-9 codes I used a lot were 611.1 for overly large breasts, 173.30 for skin cancer and 873.50 for a gnarly dog bite to the face.

The new federally mandated version, ICD-10 expands the number of codes to around  from 18.000 to 140,000 codes.  That’s a lot of codes!

Here are a few examples I might possibly need to use for cases I see in the emergency room when I am on call:  Walked into a lamppost, initial encounter W22.02XA.  And if that patient walks into the lamppost again, ICD-10 has it covered:  “Walked into a lamppost, subsequent encounter, W22.02XD.  And for that occasional patient who suffers a burn while waterskiing: V91.07XA.  I occasionally treat animal bites and in the bird department I am covered.  There are 72 codes which cover ducks, macaws, parrots, geese, turkeys and chickens.  And if the chicken bite occurs in a chicken coop, there is an add on code for that!   And if it’s a squirrel bite, of course there is a code.  But what is it something other than a bite?  There’s a code for “other encounter with a squirrel.”  Doesn’t that just make your imagination run wild???

And sometimes, I’ll see a patient late at night in the ER who along with their chicken bite and/or lamp post  injury presents with a bizarre personal appearance (R46.1) and/or a very low level of personal hygiene (R46.0). I hope they don’t take it personally because in the middle of the night, both those codes just may apply to me!

I have to keep reminding myself that the feds who mandate this stuff are from the government and they are here to help.   Sometimes I just have to scratch my head.   I wonder if there is a code for that??????

Disclosure:  I borrowed heavily form an article in the Wall Street Journal written by Anna Wilde Mathews for this topic.

Thanks for reading!  Dr. Lisa Lynn Sowder

Financial Issues, Government and Politics, This Makes Me Cranky.

Embezzelment – it was the topic of the best paper award.

February 21st, 2014 — 5:01pm

Seattle Plastic Surgeon reports the winner of “The Dom” at this week’s annual meeting of the Northwest Society of Plastic Surgeons.

blog embezellment

“He’s a rich doctor. He doesn’t need all of this money.”

This year’s meeting featured many excellent presentations on clinical outcomes, clinical research, operative techniques, patient management and lab research.  And then there was the practice management paper presented by Dr. Geoff Yule on employee embezzlement which won the highly coveted “best presentation by a member” award.    This is a very uncomfortable topic but actually a fairly common problem in medicine.  We docs aren’t quite as good at keeping track of our finances as we ought to be.  We tend to be focused on patient care (a good thing) and tend to be a very trusting bunch (mostly a good thing until someone rips us off).

Dr. Yule is in solo practice and does mostly hand surgery.  Most of his surgeon’s fees are covered by Labor and Industries or various insurance companies and health plans.  When he submits a bill for say, $743.22, for his hard work, he never, ever gets paid that amount.  He always gets paid something less because of contract agreements and payment schedules.  Thus he always has funky balance sheets with lots of write offs.  This is a situation ripe for a dishonest employee to take advantage of.  A payment here or there gets diverted to another account and shows up as a write off.  A little here and a little there can add up to a very significant embezzlement as it did in this case.

Dr. Yule was fortunate in that he discovered the dirty deed before it really threatened the viability of his practice.  Many embezzlement victims are not so lucky.   It was his very astute and savvy wife who dug deep and put all of the pieces together.

Dr. Yule presented the various parts of the investigation and emphasized how this sort of deception involving a formerly trusted employee is so painful.  He also reviewed some warning signs that are so easy to overlook when you are running a busy practice.  And then, as is so common, it turns out that this employee had a history of dishonesty but had never been prosecuted.   She was free to move onto the next trusting employer.

Well, she has not been able to move on quite so quickly this time.  She was arrested and prosecuted and is doing hard time for her crime.  Dr. Yule did the right thing to press charges and get this rip off artist off the street and out of the next doctor’s office.

Thanks for reading!  And remember – it’s better to be paranoid than sorry.  Dr. Lisa Lynn Sowder



Financial Issues

Obamacare – how it will affect my practice

December 3rd, 2013 — 2:48pm

Seattle Plastic Surgeon discusses how Obamacare will affect (or not) her practice.

blog obama careThere was a time about 10 years ago when I would have been totally stressing out over the changes coming with the Affordable Care Act a.k.a. Obamacare.  But that was then and this is now and I’m not stressing out because I don’t think Obamacare is going to affect the way I treat patients.  You see, I have not contracted with any third part payers – insurance, HMO’s, PPO’s, Medicare, Medicaid, etc. – for almost 10 years.  The only financial agreements I have for providing patient care is with my patients.

Years ago, I withdrew my contracts with all the third party payers because of lousy reimbursements and even lousier service and most of all, their interference with patient care.   Believe me, I tried to make nice with the insurance industry suits but after tearing my hair out for a couple of years, I just decided not to play any more and took my ball and went home.  And now I am so glad I did.

My patients don’t have to worry if I am “on their plan” because I am not on any plans.  And I don’t have to worry about signing lousy contracts that will put me back into the third party payer circle of hell I was in ten years ago.

I like to keep it clean, direct and transparent.  You come in with a problem.  If I think I can help, I let you know what it will cost.  (Actually most of my prices are posted on my web site.  Imagine that!)  You pay me to operate on you.  If your health plan may cover the procedure I am performing, we provide you with the information and documentation you need to take to your health plan for reimbursement.

This has worked so well for me for almost a decade and I cannot imagine going back.  I acknowledge that my situation is very different that that of a heart surgeon or a family practice doc.   But my guess is that in the next few years, more physicians will push away from their marsupial relationships with Big Insurance and Big Government and embrace a practice that allows for individualized patient care, high quality, transparent financial interactions and doctor happiness.

Thanks for reading!  Dr. Lisa Lynn Sowder

Financial Issues, Government and Politics, Health Care Costs

I am such a Girl Scout!

April 12th, 2013 — 12:34pm

Seattle Plastic Surgeon discusses the difference between reconstructive and cosmetic surgery and what that has to do with April 15th and the Girl Scouts of America.

Seattle Plastic Surgeon

I am such a Girl Scout. Please don’t ask me to fudge about the medical necessity of cosmetic procedures.

This time of year I get numerous requests from patients who want to “write off” plastic surgical procedures for tax purposes.    I am always happy to provide my clinic notes and operative reports and billing information for patients to use as they wish but I will not call a cosmetic procedure medically necessary.  Here are the definitions I use for the different categories of plastic surgery:

  • Reconstructive surgery includes those procedures that address an abnormal body structure to return to it normal or near normal appearance and/or function.
  • Cosmetic surgery include those procedures which address a normal body structure to improve appearance and/or function.

So both reconstructive and cosmetic surgery improve appearance and/or function.  The difference resides in starting point.  Was the body structure normal prior to surgery?  And, of course, the plot thickens because normal for a 65 year old is not normal for a 25 year old.  And to add more confusion, what is the function of the face?  The breast?  The nose?

Is the function of the face to provide a place for smell, breathing, taste, vision, hearing, speaking and eating?  How about the function of the face as our visual calling card?  And the breast:  Is the only function of the breast lactation or is the breast a visual calling card for femininity?

And then there is the issue of medical necessity.  What exactly does that mean?  Clearly, treatment of acute appendicitis is medically necessary.  But is it medically necessary to reconstruct a breast lost to cancer?  That reconstructed breast will never lactate.  Is it mecially necessary to treat  post-menopausal hot flashes with hormone replacement therapy or  how about replacing an arthritic hip in a 60 year old who wants to continue to play tennis?  Insurance will cover all of those above treatments but only the acute appendicitis is life threatening.

As you can see,plastic surgery is often not black and white but sometimes it is.  In those in between cases, I am happy to provide an opinion.   But I won’t stretch the truth on cases that are clearly cosmetic.

Don’t you just love it that your plastic surgeon is a Girl Scout?

Thanks for reading and have a happy tax day!  Dr. Lisa Lynn Sowder




Financial Issues, My Plastic Surgery Philosophy

Woman inherits her mother’s plastic surgery fund.

November 8th, 2012 — 12:31pm

Seattle Plastic Surgeon discusses a very thoughtful mother’s last wishes.

“To my daughter, I leave $$$$$ for the purpose of plastic surgery.”

One question I always ask when a patient is thinking about having a plastic surgery procedure is “why now?”    The answer can be very interesting and often very relavent.  Here are some answers I have received over the years:

  • I’ve always wanted to do this but my husband wouldn’t let me and now we have split up and I can do what I want.
  • I’m old enough to make my own decisions now.
  • I saw a photo of myself at my son’s graduation and was shocked when I saw my double chin.  I didn’t think it was that bad.
  • I flipped a house in Ellensburg and have the money.  (This was, of course, before the real estate crash.)
  • I finally have my kids through school and can spend the money on me instead of them.
  • I’ve worked so hard to get down to and stay at this weight and now I want to do this as a reward.

Recently I received an totally unexpected answer to this question.  My prospective patient had recently lost her  mother after a long illness.  In the last few days, the mother confided in her daughter that she had put aside some money for a face lift.  The mother was a fan of plastic surgery having benefited from a breast reduction years earlier.  She wanted to make sure her daughter used this money for plastic surgery, specifically a mommy makeover.  That mother knew that everytime her daughter slipped into her swimsuit and enjoyed her surgical result, there would be a smile and a “Thanks Mom”.

Thank you for reading!  Dr. Lisa Lynn Sowder

Body Contouring, Breast Contouring, Financial Issues, Mommy Makeover

A doctor’s take on the Medicare scrum.

September 8th, 2011 — 5:15pm

A very ugly graph

Seattle Plastic Surgeon, Dr. Lisa Lynn Sowder, blogs about Medicare.

I just can’t help but comment on the current national discussion regarding the future of Medicare. To understand how some doctors (me, for example) feel about Medicare, it may be enlightening  to look at this graph.

This ugly graph shows what doctors in private practice (me, for example) have experienced since 2000. Our practice costs keep going up while our payments from Medicare just keep dropping. I think anyone would agree after looking at these numbers that it is not unreasonable for a doctor in private practice (me, for example) might consider dropping Medicare.

In fact, I did drop Medicare about 5 years ago. I was losing money on every Medicare patient I saw and as the saying goes “you can’t make up for that in volume”.   In fact, none of the 4 surgeons in my office accept Medicare.

Talks of  further cuts in physician reimbursement is being discussed as a way to “save” Medicare but is it worth saving if fewer and fewer doctors are accepting it?   A Medicare card in your wallet is worthless if no doctors take it.  This is what is know as coverage without access.

In all of this talk of Medicare, I haven’t heard any politician discuss the fact that many doctors are choosing not to take Medicare. It is the sick old elephant in the living room.

Sorry for such a depressing topic.  Next entry, I’ll try to lighten it up.

Thanks for reading!  Dr. Lisa Lynn Sowder

Financial Issues, Government and Politics

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