November 14, 2005
Your Personal Health Record: Diagnostic and Financial - Part 2
M.J. McKeown, MD, FACOG, FACS
- As we said in See Your Personal Health Record: Diagnostic and Financial - Part 1 It is informative to learn the language of the code number systems used by all of the business side of healthcare.
It is unlikely a patient will get involved in appealing a usual and customary designation. However it is important that when an insurance company says the physician exceeded the usual and customary a patient knows that is an arbitrary number calculated to be as low as possible by the insurance company so it can pay as little as possible for any given procedure. However it is advisable for a patient to obtain and understand the code numbers used by the physician when a bill was submitted. It is also advisable for the patient to obtain the code numbers used by the insurance company when they paid the bill. It can happen that these code numbers are not the same. In one specific instance the physician submitted code numbers for the multiple diagnoses the patient had and then code numbers for the procedure done. The physician linked a specific code number to a specific procedure and charge. The insurance company picked out another diagnostic code number from the list and linked it to the procedure done and announced to the patient that they did not pay for this procedure for that diagnosis. It was only by requesting the billing records from the physician that it was possible to see what the insurance company had done. The insurance company paid for the procedure when they were notified by certified mail that their little scheme had been found out.
There is a certain vocabulary that goes with all of this. The titles used are:
1. CPT: Current Procedural Terminology
- This is copyrighted and maintained and licensed by the American Medical Association. Users must pay fees to the AMA. All physicians and clinics will have a copy and would likely allow and help a patient to find out the meaning of a certain CPT code used by their physician in any given situation. It is not uncommon to have a visit to a physician or a procedure generate more than one CPT.
- 2. HCPCS: Healthcare Common Procedures Coding System
- This is less commonly used than the CPT. If this is used in an individual case then the patient should ask the physician to have his or her staff explain the use and meanings.
- 3. ICD-9-CM This is the international classification of diseases.
- Here is where the acceptable code numbers for any diagnosis are found. It is not unusual for one visit or procedure to generate more than one ICD code.
- 4. DSM: Diagnostic and Statistical Manual of Mental Disorders
- This is the manual used by caregivers at all levels of the mental health system. It is possible for one person to have ICD, CPT and DSM codings at the same time.
- 5. EOB: Explanation of Benefits
- This is a document sent to the physician and in some cases to the patient that explains why the insurance company paid any given amount. It will also give the insurance companies reasons for not paying any given charge. If this document does not contain the CPT and ICD or other codes upon which the decisions were made then the patient will need to get these.
- 6. MIB: Medical Information Bureau
- This is an organization that is a clearing house for a persons medical record diagnoses. Insurance companies of all sorts use this when evaluating a person's health.
- These abbreviations will be used in the subsequent discussions about information the individual needs to obtain to keep a good diagnostic and financial medical record.
There is another reason to obtain a copy of the physician's written or dictated and transcribed text describing the visit in question. Brief mention was made earlier that the physician's billing adviser and clerk at times would need to tell him or her what verbiage needed to be in the record of the visit to justify the charges in case the insurance company decides to audit the text to see if there is evidence of coding to increase charges which does not seem to be supported by descriptions of the visit or in the case of procedures the detailed description of the procedure.
A final piece to this confusing picture is the MIB. This entity is a clearinghouse for a persons interactions with most healthcare situations where the bill is paid by an insurancecompany. In many cases the ICD, CPT (or DSM or HCPCS) will be there in a persons file along with the date of the visit or procedure. This allows insurance companies to check to see if the problems of a person are such that they should be denied insurance or rated up if any coverage is allowed. It also allows the insurance companies to see if some thing or other can be classified as a pre-existing condition and thus not covered in the current instance. The MIB internet site can be found at the following link. www.mib.com If one visits the site there is some verbiage that says that if a consumer requests a copy of his or her MIB record, that record is, translated from code to English. This means they will not send you the ICD, CPT or other codes the medical providers and the insurance companies have used.
What Should The Inidividual Do?
- Step One:
All of these pieces of the large puzzle that is the economic side of a persons medical record can certainly be confusing. However checking this is simpler than it seems.
- 1. For all visits and procedures obtain the verbiage or procedure or operative report.
2. Look to see if this verbiage is followed or preceded by the ICD, CPT or other codes. There may be more than one code of each type.
3. In the case of procedures or operations the CPT must be associated with ICD information that justifies the procedure or operation. For example the code for a procedure or operation will by paired with likely several ICD diagnostic codes. In many cases such acceptable pairings will have been found out by the billing clerk through the trial and error of not getting paid for something.
4. Continue to seek information for any visit, procedure, operation or hospitalization until you have the verbiage and the codes used.
- These basic descriptive codes and verbiage need to be kept along with the usual text descriptions found in a healthcare record system.
Examples of forms for adult and child health care records can be obtained at the American Health Information Management Association. (www.myphr.com). One can download free forms to adult and children's records. Other types of forms are available with a little searching of the internet. A close look at these forms will show that there is no mention of the codes just discussed above. These forms or other similar forms will be a basis to work from in building a more complete medical information and medical financial information file for yourself and your family.
- Once you have a complete record of any healthcare event with the verbiage and codes as used by your physician or a hospital you are ready to compare these with the information from the insurance company. The EOB mentioned above is where the entity paying the bills for this event will have included information on amounts charged, amounts paid, amounts adjusted, amounts denied, and amounts that are the patient's personal responsibility.
If the EOB or letter of explanation from the insurance company does not show the codes used for the charges in question then you must get them. Remember it was mentioned earlier that an insurance company denied charges for an operative procedure declaring it elective plastic surgery. However once the codes sent in by the physician were obtained and compared to the codes used by the insurance company it was easy to see that the insurance had picked a combination of ICD and CPT such that they could deny the claim. This combination was not the primary combination used for billing by the physician. This change saved the patient $12,000!
In the case of hospitalizations it is usual to find lots of codes. Hospitals generally must declare one primary diagnosis and all others are secondary. It is not unusual for the amount paid to the hospital to vary greatly depending on such coding. When you look at the copies of your hospital billing records be sure and demand a linkage to the code pairings used by the hospital to submit the bill.
The golden (your gold) rule is to always, always, always check to see that the codes used by those giving you the service and used by them to submit bills to insurance companies are the same codes the insurance companies used to either pay, adjust or deny the bill.
- Step Three:
- Be sure and request a copy of any records kept on you by the MIB. Remember they declare they will translate the codes into English before sending the report to you. Be sure and ask for the codes associated with the English so you can check and see if there is any disease mentioned there that does not fit with the data you already have from the physicians, hospitals and other providers. You may find that in attempting to get paid for seeing you some one or more of these providers of service used codes and descriptions that do not seem to agree with your memory of what was discussed with you at the time. You should check with the MIB at least once per year.
- Keeping an up to date personal health record for you and your family is excellent planning. Having these available if you find need of healthcare services away from your usual providers may be life saving. The entirety of the health record will grow to be too large to always carry with one. However it is wise to carry a summary of major illnesses, major surgeries, medications taken and any medicinal or other allergies.
The more extensive records with all the codes will keep a record of what the system used in the codes it talks. The linkages of codes and charges and payments will allow you to catch any misuse of the system by either the providers or the entities paying the bills. Once you have all this data it is easier to check with the coverage discussed in the insurance policy and what you actually had to pay. Remember to always demand a copy of the actual health care insurance policy not just some benefits pamphlet provided. Once you have a copy of the actual contract then read the fine print to be sure you understand the policies of the insurance company. In regard to Medicare and other State or Federal health insurance coverage be especially sure to read all the fine print. If the private or governmental insurance companies you are involved with offer to have you sign up to receive information bulletins be sure and do so! Remember that the area of health care insurance is especially one where Caveat Emptor (buyer beware) applies.