Trench’s Health Insurance Tips: Diagnosis Coding

Today’s healthcare pet peeve du jour is diagnoses and the coding of your medical claim.

A lot of our patients come in just for a routine check-up, a cancer screening, or they have a family history of some disease. In all 3 of those cases, an office visit or procedure are considered “routine” because an actual disease has yet to be treated and no other complaints have been presented. In some of those cases, health insurance companies do not cover routine services. So let’s take a look a little hypothetical situation shall we?

The patient comes to see the doctor for a cancer screening.

The doctor uses the diagnosis code on the claim for cancer screening.

Insurance company denies the claim because they do not cover routine procedures.

The patient gets a statement from the insurance company saying they are not paying for the visit.

Patient calls the insurance company to ask them why they didn’t pay.

This part is important so pay attention…The insurance company tells patient that they do not cover routine procedures but if your doctor had coded it as non-routine then it would have been covered.

What the patient hears is “Your doctor coded it wrong.”

The patient then calls me and wastes my time telling me that the doctor coded the claim wrong and it needs to be recoded.

Here’s where I bust the myth.

The doctor did not code it wrong. In 99% of all cases, the doctor coded it correctly with the information provided from the patient.

With the information that we have received from the patient, we can not recode the diagnosis as anything else in order to get the claim paid. That is known as INSURANCE FRAUD. I am not willing to go to jail just so you can get out of paying your bill. Health insurance is not an absolute. No matter how good your coverage is you will eventually have to pay out-of-pocket. It’s inevitable.

Do yourself and me a favor. Every year you get a booklet from your employer that goes into great detail about your health insurance coverage. READ IT! LEARN IT! LIVE IT! And stop bothering me with your assclownic questions.

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