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Jun, 25 2014

Have you ever been denied insurance because of your health history? It just happened to my friend, Carol. She applied for Life Insurance and was denied because her medical history showed a  previous diagnosis of cancer. The problem was, she never had cancer. After some digging, Carol found that a benign biopsy (not cancer) from years ago was mistakenly coded as cancerous.

What IS a medical code, anyway? As Carol found, they can wreak havoc on your life! Medical codes are used to tell insurance companies what procedures were done on you (the patient) and why, so the provider can get paid. Most provider offices rely on trained medical coding specialists to keep mistakes to a minimum. 

Medical coding specialists rely on their knowledge of medical terminology, diseases and human anatomy to assign a diagnostic or procedural code to each entry in a patient’s record. To choose the most appropriate codes, these specialists review the patient’s history and test results, and at times, talk to the patient’s doctor to uncover missing information.

Basically, there are two types of codes.

1) ICD-9 codes (also known as International Classification of Diseases) tell what’s wrong with you. 

Here’s an example:

Code #216.6 - abnormal growth of the cells that comprise the tissues of the skin, without any evidence of malignancy.  

This is a fancy way of saying you have a suspicious spot on your shoulder like Carol had. The biopsy came back negative for cancer, so the office should have used this code. Instead, the office used: 

Code #173.60 - unspecified malignant neoplasm of skin of upper limb, including shoulder. 

This code told anyone that pulled Carol’s medical history that she had been diagnosed with skin cancer. This is why the Life insurance company denied Carol’s application.

2) CPT codes (also know as Current Procedural Terminology) tell what the provider did to you.

There are thousands of CPT codes listed in a huge book published by the American Medical Association (AMA). This book is updated yearly to reflect the changes in procedures performed by providers. It is vitally important that the correct CPT code is chosen to accurately reflect what was done to a patient. For example, if you were to have an MRI (Magnetic Resonance Imaging) of your back, it’s important to know which area of your back was scanned, and whether or not it was a contrast MRI (did you have to drink a nasty dye so they could watch it travel through your system?). An MRI of the neck (CPT code 72141) has a different CPT code than an MRI of your low back (72148).

So how can you protect yourself from incorrect medical information in your medical record? Here’s 2 simple steps:

1) Review your medical bills.

As I’ve said before, OPEN YOUR MAIL! When a medical bill arrives, this is not the time to put it in a drawer. Review it for accuracy. I know it’s not fun, but a quick review of the codes on your bill can save a lot of time and headache down the road. If your bill doesn’t list the code explanations, call your insurance company or the provider for a quick review. 

2) Ask for a copy of your medical records. 

You have the right to review your medical records. Some providers charge a minimal fee for the copies. Make sure any diagnosis and procedure code used is correct. Ask for time to review with the provider’s office if you don’t understand the terminology.

3) Get help with errors.

If you find an error and need help, there are companies who specialize in Patient Advocacy. They’ll review your medical chart and bills to make sure the CPT and IDC-9 codes match your actual health history.

Now it’s your turn. Have you ever reviewed your medical record and found errors? Have you had an issue as a result of a coding error? What did you do to correct the misinformation?

Adele O’Reilly

Adele O’Reilly has over 20 years of experience in healthcare management with extensive knowledge of patient advocacy, government and commercial healthcare plans. She loved being a freshbenies member so much that she joined the team in 2013. Her passion is to help people navigate the healthcare system successfully with simple yet practical advice. Adele lives in Frisco, TX with her talented, musical family and enjoys writing plays in her (very little) spare time.

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