CHAPTER 13: Office Procedures

The efficiency of the daily operations of an occupational health facility have a great influence on client and patient acceptance. This chapter is a miscellany of practical recommendations for the smooth operation of the service.

Four general areas are covered: scheduling, billing, the preparation of protocols, and the preparation of letters of consultation.

The initial scheduling of appointments and the flow of traffic once the worker arrives presents a strong first impression to both client employer and worker-patient. A disorganized or confused process communicates a suspicion of confused medicine and conveys a very poor impression. The procedure outlined should help to avoid this problem.

Billing is well covered in most standard guides to practice management and health services administration. This is no particular approach that is unique to occupational health care facilities. Even so, a few tips may be useful and suggested billing codes for common occupational health services may be particularly helpful.

Many occupational health services are repetitive and are usually performed by nurses and laboratory staff. To ensure standardization and reproduceability of common procedures, it is important to prepare written "protocols", or step-by-step guidelines, that can be used to train new staff, to remind current staff to perform the procedures systematically, and to check performance for quality control. Protocols are illustrated using tuberculin skin testing as an example.

Writing letters of consultation is a special skill that consultants must learn in order to be effective. An appreciation for this skill is helpful in knowing how to evaluate and how to request a consultation.

Routine Scheduling

The worker-patient must be informed of where they are to go and at what time. The employer must be assured that the visit is being handled expeditiously and efficiently. The staff at each station should have a schedule of the appointments so that they can direct the worker-patient and assist in keeping his or her as close to the time scheduled as possible. Departments such as radiology and laboratory medicine must be informed to expedite occupational medicine cases. Color coding of request slips is a good idea to avoid unnecessary fumbling with papers. The staff should make every effort to return the employee to work, if warranted, as soon as possible. Note the time of departure on the encounter form. It is important to notify the employer and the workers' compensation carrier of the date the employee is to return to work or will be released for further medical treatment as soon as the date is known, so that compensation benefits can be terminated. If additional procedures are required (radiological or laboratory) that may prolong the appointment or require additional time, contact the employers carrier or the employer and inform them of the delay, giving an estimate of when the report will be available.

At the conclusion of the appointment, or as soon as possible thereafter, the employer should be contacted by telephone and informed of the status of each employee if there is any concern over the employee's fitness to return to work. The employer is not entitled to know the diagnosis, only whether the worker is fit to work at the assigned job and, if not, whether or when he or she can be expected to return to work. Paperwork should be done within 24 hours if possible. Delay in sending out forms, bills, and reports is a principal cause of dissatisfaction among employers. Communication by telephone between the client and group avoids another common source of friction - lack of timely notification.

Poor morale among clinic staff often is reflected by inappropriate or passive-aggressive behavior toward workers, especially if they present for seemingly a minor health problem or for a routine periodic health evaluation. Comments that a person can wait because he or she is "just an industrial case" are much more common than most physicians would believe because they are always said out of hearing. Such comments are very destructive, as they convey an impression to the worker that his or her case is not very important to the staff. These comments are also promptly reported back to the employer or to others in the workplace and undermine credibility in the occupational health facility. It is therefore extremely important for staff to cooperate in providing respectful, punctual, and efficient care.

The following is a sample registration procedure to expedite the handling of injured or ill workers who present to a facility for treatment. When a patient presents to one's office of facility with a health problem, the receptionist or nursing staff must determine whether the disorder is work-related or not and whether the worker has authorization from the employer to be seen. The following procedure is a step-by-step outline for receptionists and office staff to follow in handling the patient. This procedure is designed for hospitals, clinics, and physician's offices. Similar procedures for check-in, treatment, referral, and follow-up might be followed by in-plant facilities but authorization would be implied and billing procedures would not apply.

Patient Registration Procedures

  1. Checking Patient In

    1. Determine if the injury is job-related. If so, fill out the top of the Doctor's First Report form for reporting to the Workers' Compensation Board. (see Chapter 7) The physician is responsible for filling out the bottom.

    2. If the patient has been to this facility previously for a job-related injury, send for the chart.

    3. If the patient is new, register and obtain all required information for medical and billing purposes.

  2. Obtaining Authorization

    1. Complete the first part of the authorization form used by the facility. (This form follows the section on patient registration procedures.)

    2. Call the employer to obtain telephone authorization. If patient has a prior authorization from the employer by note or telephone call, no telephone call is necessary. (U.S. Federal employees will bring a special form number CA16 or CA20, which serves as both the Doctor's First Report Form and the Employer Authorization Form. If a federal employee does not bring this form, follow the standard procedure for obtaining authorization by telephone.)

    3. Note the name, title, and telephone number of person authorizing care and enter onto the authorization form and the Doctor's First Report form.

    4. If unable to obtain authorization, or if authorization is denied:

      1. Note name, title, and telephone number of person with whom you spoke.

      2. Notify patient and explain that care may be billed to personal insurance or, if none, to the patient directly if the employer or insurer refuses to honor the bill .

      3. Complete information on the registration form with notation of the worker's status as an "unauthorized patient".

  3. Treatment - Authorized

    1. Document the authorization by recording name, title, and telephone number of employer's representative.

    2. Complete the authorization form.

    3. Register the patient.

  4. Referrals

    1. If referrals or consultations are needed, the referring physician's office must obtain authorization from the insurance carrier or the employer prior to scheduling the appointment.

    2. The name, title, and telephone number of the person authorizing referral must be noted on the chart.

  5. Billing

    1. Billing information and personal information unrelated to the health problem should always be kept separate from the medical record. The medical record can be subpoenaed and should be limited to the medical aspects of the case.
    2. Complete a charge slip and insert into the billing chart.
    3. Compile all business forms pertaining to patient excluding medical forms, and place inside billing chart.
    4. Place billing chart in appropriate area for administrative pick-up and medical chart in appropriate area for medical records.

  6. Follow-Up Appointments

    If a patient has been treated for an occupational injury but returns later for the same or a new injury, a new authorization must be obtained.

Authorization for Medical Treatment (Form 13.1)


Date:  _____________    Time In:  ______________   Time Out:  ___________

_________________________________________________________________________

                                     
 To be completed by Employer          To be completed by Clinic
     
                                           Treatment Administered:

     
 ___________________________          [ ]  Office Visit - Injury Treatment
 Employee Name                        [ ]  Recheck or redress
     
 ___________________________          [ ]  Medication
 Company Name                         [ ]  Physical Exam
     
 ___________________________          [ ]  Physical Therapy
 Company Address                         
     
 ___________________________          [ ]  Refer to Specialist
 Company Phone
                                      [ ]  Return visit
                                             Date: _______ Time: _______

 ___________________________
 Workers' Compensation Courier                  Work Status:
     
                                      [ ]  Return to regular work
                                             Date: _______

 ___________________________
 Authorized Signature              
                                                Modified Work
     Status:
     
[ ]  Physical Exam   [ ]  Medical     [ ]  No prolonged standing or walking
                          Services
[ ]  Physical therapy                 [ ]  No climbing, bending, stooping
     
                                      [ ]  No prolonged sitting
     
 Modified Work:                       [ ]  No work near moving machinery
     
                                      [ ]  Limited use: right - left hand
     
[ ]  Available                        [ ]  Weight-lifting restrictions
     
[ ]  Not available
     
[ ]  Call back requested.
                                                                         
                                     
__________________________________________________________________________      

__________________________________________________________________________      

__________________________________________________________________________      

__________________________________________________________________________      

__________________________________________________________________________      


Signature of Physician: __________________________________________________      
                                                                         
                                     
     

Billing

Billing information should always be kept in a separate file from medical records. This expedites handling of the bill while the case is being worked up, keeps confidential financial information from the attention of staff dealing with the patient, and avoids unintended release of billing information if the file is suppoenaed or otherwise shared with others.

Billing for occupational health services is much like billing for any medical service. The bill should specify the patient's name, date of encounter, type of service provided, and fee. The bill should not specify the diagnosis or provide any personal details regarding the worker-patient, as these are confidential and the employer is not entitled to such information, unless communicated appropriately to a qualified occupational physician or nurse. Bills submitted to the workers' compensation board (WCB) should cover only continued occupational injuries or illnesses or services for evaluating a claim under consideration. Bills for direct health care services unrelated to work should never be submitted to the WCB. Services of a preventive nature, such as fitness-to-work evaluations, are usually covered by the employer as a business cost. Again, the bill should never divulge the medical condition of the worker or any personal information.

Billing for routine medical services, such as treatment procedures, office visits, and laboratory tests, is highly standardized and usually automated these days. Medical services are typically coded by a standard numerical coding system; in California, this is the California Standard Nomenclature, based on a system that assigns a "relative value" to each service. For example, a brief initial office visit for a new patient to establish a relatively simple medical problem (90000) carried a value of 5.9 but a comprehensive initial medical evaluation (90026) carried a value of 17.5 and a consultation for a complex medical problem (90625) carried a value of 29.0. These relative values are multiplied by a "conversion factor" (or standard fee schedule) to arise at the final fee for the service billed to the insurance company. For example, the comprehensive initial medical evaluation (90026) as billed to the California Workers' Compensation Board in 1983 would have been 17.5 (relative value) X $5.40 (conversion factor in 1983), or $94.50. The relative values are permanent under this system but the conversion factors change annually, allowing periodic adjustments without the need to renegotiate every conceivable medical service, an extremely time-consuming process. Table 13.1 shows the fee schedule current as of 1983 in California. As can be seen, surgical services carry a higher conversion factor than medical services; the relative values are intended to be consistent within but not across specialties, to allow independent adjustments of the fees. In recent years, the fee schedule for workers' compensation in California has been increasing steadily and the medical conversion factors have been slowly gaining ground.

In other jurisdictions, the workers' compensation fee schedule may be denied by other means. Since workers' compensation is a form of insurance, fees are responsive to the level usual and customary fees charged to insurance carriers in the state but are usually not quite as generous. With all these factors, there is great variation among states in the fee schedules payable for workers' compensation services. In Canada, services are typically paid at the same rate as stipulated in the fee schedule for the provincial health insurance plan and are even billed to the same agency; the only difference, ultimately, is from which account the bill is paid. The provincial insurance plan simply "back-bills" (charges for reimbursement) the workers' compensation board. This system avoids the common problem in the United States of having a bill hang in limbo, unpaid, while the insurance carrier and the workers' compensation board argue over whether the injury or illness is work-related.

A set of model service codes for specialized occupational medicine services compatible with the California Standard Nomenclature (CSN), has been developed to facilitate billing. These are presented in Table 13.2.

The majority of clinical services provided by occupational medicine practitioners are comparable to those already encoded in the CSN, differing only in the cognitive skills of the practitioner. A few common services are unique to occupational medicine, however, because they pertain to on-site plant visits, extensive consultations with employers, and urgent consultations to deal with a hazardous situation or other problem. These services have no identifiers in the present CSN, but occur sufficiently often to require a code number for billing and data management purposes.

Table 13.1. California Workers' Compensation Fee Schedule
Effective 1983

"The 1974 Revision of the 1969 California Relative Value Studies, Fifth Edition, Revised, is hereby adopted and incorporated herein by reference as though set forth in full, including procedures, unit values and follow-up days."

"The following conversion factors are hereby adopted to be applied to the sections contained in the official fee schedule approved by the Division of Industrial Accidents, State of California:

 

            Medicine Section                         $   5.40

            Surgery Section                          $ 140.00

            Radiology Section:

               Total Service                         $  11.20

               Professional Component                $   1.70

            Pathology Section                        $   1.35

            Anesthesia Section                       $  31.50


TABLE 13.2

Proposed Numerical Codes for Specialized Occupational
Health Services Provided by a Physician, Compatible With California Standard Nomenclature

     
Suggested
 Code          Name of Service            Description of Service
 and
Relative 
Values   
     
 98001      Initial On-Site        Visit to client's location to 
(18.5)      Consulation            ascertain client's needs, requiring
                                   approximately 1 hour.
     
 98011      Initial Office         Visit by client to provider's office
(17.5)      Consulation            to ascertain client's needs, requiring 
                                   approximately 1 hour.
     
 98101      Consultation Visit,    Visit to client's location to evaluate
(22.0)*     On-Site                a particular problem.
     
 98131      Routine Telephone      Telephonic consultation concerning an
(BR)        Consultation           uncomplicated problem, approximately
                                   30 minutes duration.
     
 98201      Health Hazard          Extensive survey and evaluation 
(BR)        Evaluation             of problem, may require team of 
                                   professionals.*
     
 98301      Follow-Up,             Visit to plant to evaluate progress,
(26.1)      Limited                approximately 3 hours.
     
 98302      Follow-Up              Visit to plant to assess progress in 
(15.5)*     Evaluation             resolving a complex situation.
     
 98401      Emergency Visit,       Visit on short notice to client's 
(29.0)*     On-Site                location to assist with problem which 
                                   is urgent.
     
 98431      Emergency Telephone    Telephonic consultation on an urgent 
(BR)        Consultation           problem not requiring presence on-site,
                                   approximately 30 minutes.
     
 98501      Instructional Visit,   Visit to client's location to arrange 
(13.0)      On-Site                or present a scheduled instructional
                                   program.
     
 98921      Consultation           Time spent in research, report 
(15.5)*     Services               preparation, or conceptualizing 
                                   approach and solution to problem.
     
 
     *      Per hour
     
     **     Members of such a team may include industrial hygienists,
            safety engineers, epidemiologists, toxicologists, and 
            specialized technical personnel as appropriate.
     
     BR     By report, fees to be determined on an individual basis.


The 1974 RVS has a gap in the numerical sequence in the 98000 series; these numbers are also unused in the AMA Current Procedural Terminology. Why this gap exists is not know. The proposed coding system is based on the following scheme: 98XXX The third digit represents activity (0 = exploratory discussion, 1 = consultation, 2 = health hazard evaluation, 3 = follow-up, 4 = emergency, 5 = scheduled activity such as an educational presentation, 9 = research and literature review). The fourth digit represents location (0 = client's data bank, 3 = telephonic communication). The fifth digit is a specific identifier. This scheme has been flexible enough to cover all situations encountered but has ample latitude for expansion. The relative values assigned to the codes are mutiplied by a specific fee schedule that is regularly revised.

The obsolete code 99060 "environmental intervention" should be abandoned as inadequate for describing occupational medicine services. Codes already exist for periodic health evaluation (90088, relative value 11.0), multiphasic health testing (99090) preparation of special reports (99080), and administration of a programmed medical interview (99095). Except for 90088, fees for these services are all "by report", or at the discretion of the patient.

Each service represented by a code has a fee associated with it, usually reviewed and updated once or twice a year. Fee schedules are usually kept in a computer file that can be easily updated. Nurses, physicians, and other medical staff keep track of services rendered to patients on charge slips, usually checking off common services from a long check-list and writing in codes of more unusual services. Data from these charge slips are entered into the computer, which automatically matches the codes with the current fee schedule and generates the bills.

It is often useful to keep track of the types of services being delivered to employees of a particular company as a means of tracking that company's occupational health and safety performance and need for preventive services. Also, such information may reveal that a company is utilizing the facility only for a narrow range of services - such as acute care for work-related injuries - and could be approached by marketing personnel for other services such as preplacement or periodic evaluation.

Consultation services are usually more individualized. Examples of consultation services include evaluating the validity of a workers' compensation claim, reviewing a case under litigation for medical evidence, giving testimony as an expert witness, advising on corporate policy or procedures, and designing a screening protocol for workers exposed to a particular hazard at a plant. These services do not lend themselves to the usual billing arrangement. An accepted format for such bills is given in Table 13.3.

Protocols for Clinical Services

In occupational medicine, it is desirable that procedures be standardized whenever possible and that they be defensible later if a claim is questioned. This is especially true for diagnostic or screening tests applied to large groups of workers. As a practical matter, it is usually most convenient to write a protocol, a step-by-step guide to the conduct of a particular test or procedure. Such protocols should spell out the steps to be taken, those to be documented, quality control measures, and contingincies in the event of problems. Protocols should be developed with input and review from all parties concerned, including physicians, nurses, administrators, medical records personnel, and technicians. A simple but complete protocol can greatly reduce confusion and expedite the efficient processing of patients. They are absolutely necessary when many subjects are to be tested in the same way or when testing is to be done in more than one location by different personnel.

A written protocol is also invaluable for teaching new staff and for reviewing procedures with existing staff. It lends itself to use in developing criteria for evaluating the performance of staff, as described in Chapter 31. The very act of writing a protocol forces one to think about each step in the procedure and in so doing to identify points at which decisions must be made and where efficiencies can be introduced.

Table 13.3. Billing Format for Consultation Services

STATEMENT

(Date, Year)


Re: (Patient or Plant Name, File Number)

To: (Employer's Name)

(Address)

Attention: (Official Responsible)

Medical and consultative services rendered:


1.   (Nature of activity)   X   hours at $XXX/hour        $ XXX

2.            "                      "

3.            "                      "

(etc.)
                                                       ________

                                     TOTAL             $ X,XXX 


Thank you for your prompt attention.

(Physician's Name)

(Social Security Number)

   

The following example of a protocol is for tuberculin skin testing, an inexpensive and reliable screen for exposure to tuberculosis. It was designed to permit standardized, reproducable testing to be done by nurses in several locations of a multi-centered medical group in compliance with accepted procedures. Most protocols for this purpose will likely be simpler but this example shows the concept.

TUBERCULIN SKIN TESTING PROTOCOL

  1. Tuberculin Skin Testing Policy

    1. A Registered Nurse, Licensed Vocational Nurse, or Medical Assistant, who has successfully completed a training program and guided clinical experience in the performance of skin testing may perform and interpret tuberculin skin tests upon the authorization of the physician.

    2. Each nurse who will perform the technique of skin testing will be observed in the procedure on two (2) occasions by a designated physician. A written statement verifying the nurse's competency in the procedure will be forwarded to the Nursing Department for permanent filing.

  2. Tuberculin Skin Test Record

    1. Original - upon completion of skin test reading, kept on file as permanent record of patient visit.

    2. Second Copy - Employer's record upon completion of skin test reading, presented to patient for delivery to employer.

    3. Third Copy - presented to patient for personal records.

    4. Fourth Copy - Forward to Accounting Dept. at end of day.

  3. Responsibilities of Receptionist

    NOTE: A separate Appointment Book will be utilized and non-contract patients notified of pre-payment fee.

    1. Scheduling Hours (Initial and Return Appointments)

    2. Day of Appointment

      1. Register patient. (Instruct patient to fill out top portion of Tuberculin Skin Test Record Form).

      2. Collect fee if appropriate. Mark paid and amount in appropriate section on record form and sign using first initial and last name. Detach fourth copy and place in cash drawer.

      3. Place Record Form, intact, in appropriate place for nurse.

    3. Scheduling Return Visit

      1. Schedule return visit for Skin Test Reading as indicated on back of third copy of Record Form.

      2. Provide the patient with an appointment card.

      3. Place Tuberculin Skin Test Record Form intact in Return Visit File.

    4. Day of Return Visit for Skin Test Reading

      1. Pull Tuberculin Skin Test Record form from file in anticipation of scheduled arrival.

      2. Upon patient's arrival, place Record Form intact, in appropriate place for nurse.

      3. Upon completion of skin test reading, when patient returns to receptionist desk, separate Record Form:

        1. Original - place in permanent file.

        2. Second Copy: Private patients - present to patient to carry to Employer. Contract patient - included within other charges at end of day and forwarded to Occupational Medicine desk.

        3. Third Copy - presented to patient for personal records.

  4. Responsibilities of Nurse

    1. Day of Appointment

      1. Calls and greets patient and escorts to testing area

        (Examination Room if available, or urses Station).

      2. Briefly explains the procedure and asks the following questions:

        1. "Have you ever had tuberculosis or a positive TB Skin test in the past?"

          NOTE: If the patient's answer is "yes" - DO NOT TEST THE PATIENT. If the patient is unsure - seek medical (physician) assistance.

        2. "Are you taking steriods, cortisone, ACTH, cancer chemotherapy drugs to suppress organ tranplant rejection?"

          If the answer is "yes" - seek medical assistance

    2. Equipment

      Tuberculin Syringe with #27-1/2 needle

      (Sterile Technique) Solution of Purified Protein Derivative

      (5 ml. vial - use 0.1 ml.)
      Alcohol sponge Felt marking pen

    3. Preparation and Administration

      1. Withdraw (exactly) 0.1 ml. of PPD into a (1.0 ml.) Tuberculin Syringe with #27-1/2 needle. NOTE: DO NOT attempt to second-guess dead space in syringe.

      2. Cleanse the skin of the volar forearm with the alcohol sponge - same side as the palm of the hand. NOTE: Use non-dominant arm.

      3. Hold the forearm skin taut, holding the syringe with the needle bevel facing up, inject the full quantity of P.P.D. into the forearm - away from the large veins, scars, rashes or wounds.

      4. A visible bleb should rise just over the needle point of injection. If this does not occur, the injection was not intra-dermal, and the test is invalid.

      5. Mark the location on the patient's forearm by circling the injection site with a felt pen.

      6. Instruct the patient to return for a reading in 48 hours (72 hours).

        If the patient delays beyond 72 hours, seek medical assistance in interpreting the test. NOTE: Tests cannot be read before 48 hours have elapsed.

      7. Record date done, time, PPD and strength with amount on Tuberculin Skin Test Record form - including signature.

    4. Skin Test Reading

      1. Find injection site by locating felt marker circle on forearm.

      2. Ignore any redness visible at injection site.

      3. Run your finger over the injection site.

        If you feel a hard, button-like, firm area of "induration" in the skin, note where the edges are located.

      4. Utilizing a millimeter ruller, measure the diameter of the induration across the center, from edge to opposite edge, perpendicular to the long axis of the arm.

        Record this measurement in millimeters (mm).

    5. Interpreting the Skin Test

      1. None to 5 mm = Negative reaction.

      2. 5 mm to 10 mm = Negative (unless there is a reason to suspect recent exposure to tuberculosis). Must be questioned by the nurse.

      3. 10 mm or greater = Positive

      4. 25 mm or greater; with warmth and heavy redness = Strongly positive, sloughing reaction.

      5. All positive readings are to be checked by physician or designate.

      6. If reading is 25 mm. or greater, MUST be seen by a physician for follow-up.

      7. If chest film is ordered in the presence of a positive reaction, patient must be registered as new patient.

    6. Follow-up Action

      1. Negative Reaction: Advise patient and record.

      2. Positive Reaction: Advise patient that medical evaluation is required without undue delay and that treatment may be required and record.

      3. Sloughing Reaction: Seek immediate medical assistance and record. NOTE: Repeat skin tests should not be given for several weeks, and should NEVER be given to an individual know to have had a sloughing reaction in the past.

      4. Provide patient with Record Form (intact) with instructions to proceed to receptionists' desk.

Consultation Notes

A good letter of consultation should be concise, informative, helpful to the referring physician or agency, and as specific as possible in recommending measures for the patient's benefit.

Two actual letters of consultation are reproduced below. The first was prepared by an experienced occupational physician dealing with a very complicated case. It summarizes the case in enough detail to stand alone as a record, clarifies the issues of primary concern, stipulates what steps were taken with regard to medical confidentiality, educates the referring physician without assuming a condescending tone, outlines the recommended management of the case, and ends cordially. Compare this with the second letter, written by a full professor at a (non-Canadian) prestigious medical school. Despite the second clinician's excellent credentials, his consultation report is utterly useless by comparison to the first.

The first consultation report is recommended as a model to follow:


RE:          Mr. A.
__________________________

Dear Dr. B:

Thank you for referring Mr. A to us for evaluation. I have also received the subsequent communication from Dr. C, Occupational Health physician for the D Corporation. I have discussed with Mr. A the propriety of sharing information with Dr. C and have obtained his written permission to disclose pertinent information. He has no objection and the corporate policy of the D corporation precludes communication of confidential information from the Occupational Health service to management. Thus, by copy of this letter I am reporting to Dr. C as well in communicating our findings.

Mr. A's history is well known to you but I shall summarize it for the record. He is a 32 year-old male chemical plant worker who since November 1985 has had a series of unexplained abnormalities on blood tests taken as part of his routine periodic health surveillance. The cause of his mild liver function abnormalities is not clear but may be associated with exposure on the job or endogenous causes of which there are two candidates. Mr. A has had a persistant abnormality of his serum cholesterol, raising the possibility of an hyperlipoproteinemia. He is also an obligate heterozygote for one of the mucopolysaccharidoses, which affects his son.

His past medical history is unremarkable except that his family history is very strong for coronary artery disease and stroke in all close relatives. He does not smoke and has not drunk alcohol for at least eight years. He is on a diabetic diet but is taking no medication except diclofenac for back pain as needed. (This drug is known to elevate transaminases and can cause jaundice and hepatitis.) He has no known allergies. He has no history of hepatitis or mononucleosis and has received no transfusions.

Physical examination showed a normal liver span and no palpable spleen. He showed no xanthomata although he did have hyperpigmentation over his shins.

Examination of his pattern of abnormality shows little discernible pattern with the LDH and the alkaline phosphatase elevated. The transaminases are variably elevated, only once being synchronous, on 18 July 1985. In each case the elevations have been minor, except for the elevated SGPT on that date. By comparison, however, the serum cholesterol has been consistently elevated and the triglycerides have been consistently and markedly elevated. A lipoprotein electropheresis was performed on the request of Dr. C, of the D Corporation, on 27 November 1986. This shows an elevated pre-beta and beta bands interpreted as being either a primary or secondary type 11B pattern.

This presents us with a very interesting diagnostic dilemma.

I have reviewed what little literature exists on the liver function of individuals with this disorder and have consulted with our local University Hereditary Diseases Program in an effort to search out what is known. Liver function abnormality in children affected with the disorder apparently occurs quite late as a result of the storage disease and is nonspecific in its presentation. Although we can find no specific report of heterozygotes being tested for liver function abnormalities, its absence in the early stages of homozygotes strongly argues against its presence in their parents in the absence of another cause. Logically, there is no reason why the heterozygote condition should interfere with normal liver function. Thus, I think that we can safely dismiss this as a cause of his condition.

Occupational exposures are of concern. His most significant exposure is benzene but there are several other chemicals in the two units in which he works that could be hepatotoxic. In each case, however, for these chemical to cause liver function abnormalities he would have had to have been exposed at very high concentrations. Such concentrations do not appear to be at all likely in his workplace. The extremely variable pattern of the abnormality also argues against a chemical hepatitis, since one would expect the transaminases to be more consistently elevated. Thus, I believe that we can conclude that occupational exposure is unlikely to be the cause.

Mr. A does, clearly, have a type IIB hyperlipoproteinemia and given the family history it is almost certain primary. He clearly is significantly affected clinically and is at some risk if his elevated serum cholesterol level is not brought under control. It is my conclusion that his unusual pattern of liver function abnormalities probably is the result of a low-grade fatty liver associated with his hyperlipoproteinemia. This would explain its variable presentation, the lack of associated clinical abnormalities, the occasional elevation of the alkaline phosphatase (which would be quite unusual in chemical hepatitis) and its association with the lipid abnormalities.

Given the history and the relatively benign clinical course of his condition, I would be reluctant to recommend a liver biopsy. You may, however, be more confident in the diagnosis if a liver scan is performed to rule out a space-occupying lesion or if a serum 5'-nucleotidase is elevated, confirming the hepatitic origin of the elevated alkaline phosphatase in the absence of an elevation in the bilirubin, since this pattern is characteristic of fatty liver. I would suggest following Mr. A very closely because of his hyperlipoproteinemia but I would consider the liver function abnormalities a very minor part of the problem likely to correct itself when the lipid abnormality is brought under control.

Thank you very much for referring this most interesting case. I must say I enjoyed sorting it out and appreciate the opportunity. Please let me know how he gets along and please do not hesitate to give me a call if I can be of further assistance.

Sincerely,

"Doctor E"

The following example is not recommended. Indeed, it is appalling to think that a medical consultant would actually have sent such a letter in response to a serious referral. It is presented just as it was received:

Dear Dr. X:

I examined Ms. Y after reviewing the reports you kindly sent me. Her symptoms are of 3 kinds.

  1. Eyes--watery, burning, pink to red conjunctivae, swollen lids. Exacerbated after visit to department store, around lacquer, handling new clothing. May occur during suspected exposure to a chemical of some kind or 2 hours later.

    Other provoking factor--photocopying devices, manufacturing area of her present job.

  2. Gagging sensation in throat, soreness in throat. This symptom may be associated with (1) above, and seems to increase with increased concentration of chemical.
  3. Rash on face, chest--deep, hard, painful nodules, embarrassing. These have been present to some degree for over 1 year and thus are not intermittent, as (1) and (2) above.
  4. Accumulation of fluid everywhere, especially the mucus membranes if the reactions are severe.

This set of symptomatology is dated from the visits to the Z factory between March and May, 1982, that were previously documented.

Environment at home-- no unusual exposures or contacts. Has 2 Siamese cats for many years. Now living alone.

Mrs. Y wants to know if her reactions can be cumulative and cause permanent illness. She does not want to undergo standard diagnostic allergy tests, but would prefer a blood test that could be checked regularly to determine if she is improving.

Physical exam: BP 112/80 T-36.8oC FEV1-2.6 L FVC=3.1 L PEFR=430 L/M

EENT, lungs and heart were within normal limits. A cystic acneiform eruption was present on the cheeks and upper torso.

Impression: Variable non-specific symptoms attributed to various chemical exposures dating to a series of work-related factory exposures in March-May 1982.

Advice:

  1. There is no reason to believe that she should not improve provided that excess chemical contacts are avoided.
  2. A personal physician, perhaps an internist, should be obtained in order to give Mrs. Y a continuum of medical attention.
  3. She may wish to consult a dermatologist about her skin condition.

Sincerely,

"Doctor F"

Note that in this consultation letter the clinical description is vague and not convincingly associated with the exposure on the job by the consulting physician, in part because the consultant appears to have had no idea of what exposures her actual job might have entailed. The note is awkward in style and there are mistakes in format (e.g. "symptoms of 3 kinds" when four are given) and wording ("These have been present to some degree for over 1 year and thus are not intermittent...") that suggests a very casual dictation and probably casual thinking as well. The findings on physical examination do not relate to the complaint (e.g. fluid retention is described in the complaint but no mention is made of the presence or absence of edema on examination). Cystic acne is very unlikely to be associated with the kinds of chemical exposure encountered in a department store or on exposure to lacquer, but no attempt seems to have been made to find this out. Instead, the consultant flies "by the seat of his pants" giving a very general opinion that will deprive the patient of her job for no good reason. The letter also does not address the patient's own concerns about monitoring her improvement but reports test results (pulmonary function tests) that seemingly have nothing to do with her complaints. Finally, the letter insults the referring physician by suggesting referral of the case to another physician to provide "a continuum of medical attention".

This second letter is an extreme example of how not to write a consultation letter. It incorporates almost every serious mistake a consultant can make and therefore is well worth studying as an example of what to avoid.

Just as it is a responsibility of the consultant to be responsive to the questions being raised, it is incumbent on the referring physician or agency to state clearly what is being asked. The following sample consultation form contains most of the basic information a consultant in occupational medicine needs to know initially and provides a convenient format for requesting a consultation when required.

REQUEST FOR CONSULTATION (Form 13.2)

 Patient's Name: ____________________  Insurance #: _____________________

 Address: ___________________________  No Insurance #:    (  ) Check

          ___________________________  Phone: ___________________________


 Referring Physician: ___________________  AHCIP Referral #: ____________

 Address: _______________________________  Physician's Phone: ___________

          _______________________________  Specialty: ___________________



     
 Patient's Current Occupation: _________________________________________

 Occupational Status:      (  ) Employed           (  ) Disabled 

                           (  ) Unemployed         (  ) Retired


 Chief Complaint: ______________________________________________________


     
 What Questions Do You Wish Us to Address?:  
   (Please use reverse of this sheet if needed.)

 _______________________________________________________________________

 _______________________________________________________________________

 _______________________________________________________________________
     
                                            
     
 Other Physicians Who Have Evaluated Patient For This Problem: _________

 _______________________________________________________________________

 _______________________________________________________________________
                              



 Do You Wish Us to Telephone Our Findings Immediately?:    (  )  Yes




 Date of Request: _______________  Doctor's Signature: _________________



Further Reading

California Medical Association. California Standard Nomenclature. San Francisco, Sutter Publications, 1979.

California edical Association. California Relative Value Studies, 1974 Revision. San Francisco, Sutter Publications, 1975.

Official Medical Fee Schedule for Services Rendered Under the California Workers' Compensation Laws. San Francisco California Workers' Compensation Institute, 1980, updated annually.