On Health Insurance, part 3

27 May

It’s been a while, and before I start writing about my new field of questionable expertise, I have a few more posts about healthcare to churn out. Today’s topic? Breaking the Code: understanding what the hell gets your doctor his money. Every claim that your healthcare provider files with your insurance is going to be covered in codes, and if you need preauthorization or a referral, you might need to know what some of those codes mean so you don’t spend the next seven months wrestling with customer service representatives. That kind of stress is only going to send you back to the doctor, after all, and then the whole things starts all over again.

Place of Service code: This code is less significant than most, and you’ll likely never need to know the codes themselves, just the places they represent. But it’s occasionally important to know where your service is supposedly taking place. For the most part, your service will probably be submitted as an Office or Facility place of service. However, if you’re getting home healthcare, place of service (you guessed it) Home, then you may need to get extra special authorizations, because your insurance hates paying extra for someone to help you out at your house. This is something to keep an eye on if your claim gets denied after you were told you didn’t need to get an authorization.

ICD-9 code: We’re actually moving along toward ICD-10 now, but that’s beside the point. ICD stands for International Classification of Diseases, and for most medical claims, there’s going to be one of these. This is also known as a diagnosis code. Any time you go to the doctor for anything that’s wrong–you have the sniffles, or heart palpitations, or you’re bleeding internally–there’s a code representing that owie, no matter how big or small.

Okay, so your illness becomes a little string of numbers. How is that important? Well, it may affect your insurance coverage in several ways. First off, if you’re going in for your annual physical, chances are that it’s covered in a special way as part of preventative care. The trick? If you also mention that your elbow hurts, and your doctor puts that down as an ICD-9 on your physical visit claim? Then it’s no longer preventative care, and you’re gonna have your deductible come bite you in the butt. Your diagnosis may also limit the types of care that you can get; your insurance may have limitations on what it thinks is “medically necessary” as far as tests and treatments for certain diagnoses. A bizarre example? If you have Iowa Medicaid, and you have tachycardia (785.0, rapid heart rate in layman’s terms), you’re not covered for any outpatient heart monitoring.

Well, it’s weird to me.

CPT or HCPCS Code: For every type of office visit, every test, surgery, or piece of medical equipment, there’s got to be a CPT code or HCPCS code. This is a code that corresponds to a description that explains what the heck your provider is doing that he or she or they deserve(s) to be paid for. Now, there’s a lot of letters involved here. You’ve got your Common Procedural Terminology and your Healthcare Common Procedural Coding System. Both of them claim to be common, and both of them largely duplicate the other. The difference here? One of them is published by CMS, The Centers for Medicare and Medicaid Services. That’d be your HCPCS, and CMS is a government agency, which means HCPCS belongs to the people. CPT codes, however, are published by the American Medical Association. They’re copyrighted by them too, which means that they can charge you for using them. That’s right. The AMA owns part of your medical claim. Sadly, guess which list is more frequently used?

Why do you need to know about this code? This is really the most important code on the whole claim, since it’s the whole point of submitting the claim. And since codes can be very similar in number and description but have very different requirements as far as preauthorizations or coverage period, if you’re getting a major procedure done, you may want to call ahead to the provider and get the procedure code they’ll be using, then use that to check with your insurer about what enchanted rain dance you may need to do beforehand in order to get the money gods to shower down funds upon your doctor.

Really, that’s today’s whole lesson. When in doubt, get the code and call your insurer. Your provider may call and verify your benefits for you if they’re really awesome, but chances are your insurance will be a bit more attentive to you since you’re the one giving them money, not merely taking it away.


4 Responses to “On Health Insurance, part 3”

  1. louhish May 28, 2011 at 2:19 am #

    I did commercial insurance follow-up for an ambulance company for a while. It’s worth noting that some diagnosis codes are more specific than others- and EMS can’t send in a claim with the “broken arm” diagnosis, unless they see bones poking out and whatnot. Generally, they’ll need to use “arm pain”, because it’s not until you get the Xray that you’re sure it’s broken. This causes problems with some insurance companies, who prefer to assign a primary diagnosis to an incident, and then only pay the claims with that primary diagnosis.

  2. Fallah May 28, 2011 at 12:21 pm #

    This is actually really helpful for me right now. Some of my PCOS treatments fall under one category that is covered by my insurance, and some fall under infertility treatments, which are not (and whether they should be is a whole separate issue we won’t get into here).

    Now I know what to ask the office about before I actually have any future ultrasounds or procedures done.

    • haemonic May 29, 2011 at 5:05 pm #

      I cannot tell you how much of a relief it is to know that someone is finding some use in these posts. =D


  1. On Health Insurance, Part 4 « Seven Deadly Divas - June 8, 2011

    […] the CPT codes I talked about last time? The AMA created those in 1966. Originally they had nothing to do with getting paid; they were just […]

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