You fall and gash your
hand. You need stitches, which your doctor
describes as 12002.
Your continuing heartburn problems result in a
diagnosis of GERD. But your doctor’s paperwork
says you suffer from 530.81.
No matter what we patients call our medical
challenges, our providers and payers use a
different language -- medical codes -- to manage
our care. These codes describe how we are
diagnosed and what our diagnosis is, control the
services and treatments we get, and, of course,
determine how it all gets paid for.
To get the best care possible, we patients need
to understand medical coding systems, and why
they are important to us.
Current Procedural Terminology, CPT codes were
developed by the American Medical Association to
help physicians and their insurers speak the
same language about reimbursement. 12002 is the
code for stitching a wound up to 3+ inches wide,
for which a doctor in Syracuse, New York will be
paid $143.13. A larger gash would require a
different code and more reimbursement. A doctor
in another location might get paid more or less
for that same code. Medicare uses mostly the
same system, but calls them HCPCS (Healthcare
Common Procedure Coding System) codes.
ICD (International Classification of Diseases)
are diagnosis codes developed by the World
Health Organization, and are used across the
globe to signify the same disease or condition.
For example, 250.0 means diabetes in Syracuse,
Zurich, Tokyo and elsewhere. ICD codes may also
be found on death certificates, and are used to
trace contagion routes of infectious diseases.
In the United States, insurers use ICD codes to
determine whether they will reimburse providers
for tests or treatments. For example, if your
paperwork reflects 530.81 for your heartburn,
your insurance won’t pay for a CT scan of your
leg or a prescription for a skin rash.
We patients find CPT and ICD codes on the
paperwork, receipts and bills we receive from
our doctors and payers. Tracking these codes
grows increasingly important since mistakes can
affect our care and wallets. Miscoded records
may mean we are refused necessary treatments.
Upcoding, the attempt by a provider to be
reimbursed for higher-end services, or even
services never provided, can reflect a simple
mistake, or evidence of fraud.
Find more information about coding systems used
by providers and payers, plus tools for matching
specific codes to their diagnosis, test, service
or treatment, at
http://bit.ly/medcodes.
