Cracking the codes on your medical bills
If you’re like most consumers, you don’t know what that medical code means, but that unfamiliarity could cost you.
The above Current Procedural Terminology, or CPT code, for a breast biopsy is an example of a commonly used medical billing language. It’s one of two — the other is the International Classification of Diseases (ICD) code system — that health care providers primarily use to convey to insurers what treatment and services they provided to patients. If the billing department gets it wrong, your insurer may not pay — leaving you on the hook.
Health care billing experts who spoke with Angie’s List say it’s tempting to look only at the bottom line of your medical bill for what it says you owe. But overlooking other vital information — like the date of service, billing code, number of units delivered, diagnosis, or service description — is a mistake. Errors could lead insurers to deny claims or apply charges to your deductible.
Angie’s List member JoAnna Farrell of Fredericksburg, Va., learned firsthand how an incorrect billing code could disrupt life.
After having a breast biopsy, Farrell says she spent nearly two years disputing $549 in charges for a biopsy clip kit she never received. Farrell says the office worked with her to try to correct the error, but she still felt compelled to make monthly payments toward the bill to keep the provider from sending it to a debt collection agency.
Related: How to dispute a medical bill
Farrell says she eventually hired patient advocate Gina Warner, owner of Warner Medical Billing Consultants in Newport News, Va., to get the provider to correct the error. “It was cleaned up within one week of Gina Warner [contacting the center] because she knew how to talk the talk,” Farrell says. “She knows the codes.”
In addition to impacting how much you pay, a miscoded diagnosis could affect your ability to get disability or life insurance, or lead to inappropriate medical care, Warner says. “If it’s [incorrect] in your medical chart, it’s conflicting information that could influence your care,” she says.
Consumers can learn what CPT codes mean via the AMA’s CPT Code/Relative Value search page. Warner recommends searching your insurer’s website or contacting its member services department for the latest ICD code information. Medicare patients also can call 800-MEDICARE (800-633-4227).
After working with Warner to address the biopsy clip billing error, Farrell says she’s being proactive and now learns what the codes on her billing statements mean. Doing so helped her get charges removed for a pregnancy test done prior to a gallbladder procedure. Farrell says she told doctors and lab technicians beforehand that she didn’t need or want the test. “They were going to charge me $200 for a pregnancy test. I’m in menopause. I filled out three forms saying I wasn’t pregnant,” she says.
Michael von Arx, director of compliance for highly rated Oregon Imaging Centers in Eugene, says some codes are for supplies or devices commonly used in a procedure. If some components weren’t provided, the insurer typically decides if the payment is reduced. “This is why it is so vital that patients look at their EOB statements,” he says.
“If an insurer denies a claim, ask why,” von Arx says. “Sometimes insurance won’t pay if they think the procedure wasn’t medically necessary.”
Member John Murray of Highlands Ranch, Colo., says he’s more than five months into disputing his insurer’s decision to deny a $14,500 claim for six days of neonatal intensive care in November 2013 for his premature son at highly rated Swedish Medical Center in Englewood, because the insurer says the NICU doctors were out of network.
The Health Insurance Portability and Accountability Act prevents providers from disclosing patient-specific information, says Swedish Medical Center spokeswoman Nicole Williams, but if hospital patients are billed by NICU doctors that are out of network, its finance department will work with the physicians’ staffs and insurers on behalf of patients to honor the insurer’s in-network prices.
Williams adds that patients should always start with their health care providers to resolve billing issues. “The hospital is the origin of the medical record and the insurance billing,” Williams says. “We are also a very large entity that has relationships and business interactions with the insurance providers on a daily basis, so our ability to get things sorted, negotiated or otherwise, when appropriate, is much more effective than the patient calling the insurance company.”