I’m going to start and end this article with a video. Here’s the first one:
First, the word I couldn’t remember when doing the video was “cosmetic”. In essence, all the insurance company knew was that I was having some kind of surgery on my left breast to remove “something” without any extra details. In their eyes, the lump could have been on the outside of my body or some kind of polyp that was growing inside my body but was benign, which means it wasn’t dangerous in any way, we just wanted to get rid of it.
As you heard, once I made a call to the insurance company (major tip; if you have any questions regarding either billing or coding issues and coverage by an insurance company, get on the phone and call them!) and gave them a few more facts, they helped me to get the proper codes so the surgery would be covered. What you need to know before you ever contact an insurance company about something like this is the code the physician’s office or hospital was going to use to submit for the procedure (hospitals would do this type of thing when trying to get authorization for a procedure being performed there). If you show insurance companies that you have even the smallest bit of knowledge about what’s going on, they tend to be more helpful; that’s just how humans are sometimes. 🙂
I was never a certified diagnosis coder, so that’s not one of the areas where I’m going to be digging deep into. However, I did read a lot of medical records back in the day, and I had a good feeling for when codes might not match up with what it said in the medical record. For instance, a lot of hospitals code surgical procedures using ICD codes instead of CPT codes to try to be more accurate. The problem comes when a coder makes a decision based on their interpretation of what was written down instead of what is actually in the medical record. Those that stick with using CPT codes to code surgical procedures (such as endoscopic procedures) might disagree with what the department said they did, but didn’t indicate it in the medical record properly.
Making assumptions without verifying with the department what actually happened can result in either upcoding or undercoding issues. Undercoding could mean that you get reimbursed less than you should have been paid, while upcoding means your facility is billing for something to get more money because the diagnosis code isn’t matching what was written in the medical record, which could get your facility being accused of fraud. This happens more often than you’d believe, because ancillary departments aren’t necessarily taught how they should be capturing what’s going on and entering it into the medical record. For that matter, procedures that are done on the floors by nurses or other medical professionals isn’t always captured properly either.
I was consulting in a hospital in Pennsylvania back in the late 2000’s, a couple of years after new infusion codes had been added to the CPT manual. I was in a discussion with both the person who was over the charge master at the time (an accountant who only looked at the CDM once or twice a year), a couple of nurses who worked on one of the floors, and the director of medical records.
There was a minor debate because not only had those codes not been added to the charge master, but medical records and the nurses on the floors didn’t know that they were supposed to be recording time for infusion services. It stated clearly in the manual that there are codes for intravenous infusion for hydration and intravenous infusion for therapy (the range 96360 – 96371). The main codes cover 31 minutes to an hour (any infusion under an hour is nonbillable), and the secondary codes after each main code is per hour after that. The therapy codes also include charging for multiple drips at the same time, which is common for inpatients.
Without any indication in the medical record that the drips had been timed, along with the time that the procedures began, that part of the medical record has to be considered invalidated and can’t be coded as any kind of procedure in today’s ICD–10 world. In some ways it might seem like a minor thing, but there’s no such thing as minor coding issues in health care, especially when there are now 111,000+ codes as compared to the 16,000 we used to have to deal with.
One of the nurses wasn’t happy, saying they’d never done it and it would be hard for them to record “everything” they did. I had to remind them that this wasn’t my instructions, but the regulations of proper information gathering. Frankly, I was surprised by this because I’d always thought it was something all nurses did to begin with. This is more proof that we can never assume what others are doing without verification.
As a sidebar addition to this story, the reason I caught it in the first place was because a high number of Medicare claims were being denied because it turns out that not only had the hospital not added the new codes to the charge master, but the computer company they had purchased their software from also didn’t know about the new codes, so they had never put it into their system. I ended up having to scan the pages showing them what I was telling them was accurate, because they didn’t believe me and that irked me to no end. lol
I’m ending this relatively short article with the second video, this one talking about how physicians often up code claims for the patients they see, and how it can be fruitless trying to get them to reevaluate what they’ve done. I share this because if it can happen in the private physician world, it can happen in the world where physicians are working inside the hospital, since they are supposed to have their own report that goes into the medical record.