You fall and gash your hand. You need stitches, which your doctor describes as 12002.
Your continuing heartburn problems result in a diagnosis of GERD. But your doctor’s paperwork says you suffer from 530.81.
No matter what we patients call our medical challenges, our providers and payers use a different language — medical codes — to manage our care. These codes describe how we are diagnosed and what our diagnosis is, control the services and treatments we get, and, of course, determine how it all gets paid for.
To get the best care possible, we patients need to understand medical coding systems, and why they are important to us.
Current Procedural Terminology, CPT codes were developed by the American Medical Association to help physicians and their insurers speak the same language about reimbursement. 12002 is the code for stitching a wound up to 3+ inches wide, for which a doctor in Central New York will be paid $143.13. A larger gash would require a different code and more reimbursement. A doctor in another location might get paid more or less for that same code. Medicare uses mostly the same system, but calls them HCPCS (Healthcare Common Procedure Coding System) codes.
ICD (International Classification of Diseases) are diagnosis codes developed by the World Health Organization, and are used across the globe to signify the same disease or condition. For example, 250.0 means diabetes in Syracuse, Zurich, Tokyo and elsewhere. ICD codes may also be found on death certificates, and are used to trace contagion routes of infectious diseases.
In the United States, insurers use ICD codes to determine whether they will reimburse providers for tests or treatments. For example, if your paperwork reflects 530.81 for your heartburn, your insurance won’t pay for a CT scan of your leg or a prescription for a skin rash.
We patients find CPT and ICD codes on the paperwork, receipts and bills we receive from our doctors and payers. Tracking these medical codes grows increasingly important since mistakes can affect our care and wallets. Miscoded records may mean we are refused necessary treatments. Upcoding, the attempt by a provider to be reimbursed for higher-end services, or even services never provided, can reflect a simple mistake, or evidence of fraud.
Find more information about coding systems used by providers and payers, plus tools for matching specific medical codes to their diagnosis, test, service or treatment, at http://bit.ly/medcodes .
If you need help understanding your bills, medical codes or correcting billing errors, ReAssured Advocacy can help. Call us at 303-756-8436.
Reprinted with permission from Trisha Torrey, Every Patient’s Advocate: www.EveryPatientsAdvocate.com
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