I've Got a Secret!

If a doctor wants to get his ir her bills paid by a carrier, they must know all of the secret codes to use. Think I am kidding? Well, maybe just a little…

The truth is a doctor can’t just bill an insurance company by saying “The patient has the flu – I examined her and gave her a good going over – you owe $75 for the office visit.”. No, the doctor must submit special codes to the insurance carrier that tell the carrier what was wrong and what he did to fix it.

These codes, developed and published by the AMA, fall into 2 distinct types: ICD (International Classification of Disease) or diagnosis codes specify what is wrong with the patient. CPT (Current Procedural Terminology) specifies what was done to the patient.

Actually, these codes are a great idea. They allow medicine to become more objective, and thereby allow real statistical data to be gathered and compiled on different diseases. Like most things, in life, the devil is in the details…

Insurance carriers use these codes to deny valid claims whenever they can. The doctor must use the proper CPT code with the proper ICD code, or risk not getting the insurance claim paid. There is enough vagrancy within the code system so that the carriers have enough ‘wiggle room’ to deny a valid claim. There are ‘modifiers’ or 2 digit codes that are added to the end of a 5 digit CPT code that give more specific details about that particular procedure. Some carriers require as many as 3 additional modifier codes attached to each procedure code. What makes matters worse, the coding rules can vary from carrier to carrier, or even between different plans from the same carrier. And these requirements constantly change. If the doctor does not follow these rules, they risk lower payments from the carrier, or even denial or the claim altogether. In the worse case scenario, doctors are accused of ‘insurance fraud’ if they use the wrong code or modifier – even when the doctor has decided that those codes best described that particular patient encounter. This has created an entire industry of ‘coding’ newsletters and seminars. Most offices spend thousands of dollars each year on coding manuals and staff training, just to stay on top of the coding shell game. Larger practices will have at least one person whose job is to ensure proper coding

One of the largest players in the coding game is a company call Ingenix. Ingenix has an entire series of coding manuals that are updated each year. A complete set of these manuals cost several thousand dollars. Part of this set is a ‘Fee Analyzer’ that shows doctors what other physicians in their area and specialty charge for each procedure code (Doctors are not permitted by law to discuss their fees directly with each other). Ingenix also publishes the same type of data for use by insurance carriers to aid them in determining what to pay doctors for each procedure. The interesting thing is that these two Ingenix data sets have little to no correlation.

It’s also interesting to note that Ingenix is owned by the UnitedHealth Group, that also owns United Healthcare, one of the largest health insurance carriers in the country. So, basically, we have doctor’s paying significant sums of money to a company that tells them what they can charge an insurance company for their services. And that company is owned by an insurance company. Talk about letting the fox guard the chicken coop…






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