Decoding Coding

Clever title…but I have yet to decode coding.

\"MisterMindDecoder\"

I had a woman come in my office a few weeks ago with some small lumps under her skin on her arm.  To get paid for this, I had to code the problem.  Fortunately for me, I have an EMR and can immediately look up the code for the problem at hand.  This works just fine when it is a common problem or symptom, such as shortness of breath, chest pain, foot pain, or migraine headache.  Do you think I found a code for \”little hard nodules under the skin on the arm\”?

Why did I have to code this?  Coding is how doctors get paid.  Finding the proper code allows me to bill for fact that I addressed that problem in the visit.  Improperly coded problems will be rejected by the payers, so I don\’t get paid for my work.  I can do a wonderful job with my patient in the room, document perfectly, but the wrong code will result in an automatic rejection.  So what do I do when the problem is like the one this lady had?  I get as close as possible – \”Subcutaneous nodules, NOS\” –  \”NOS\” means Not Otherwise Stated, which means it is just playing the game correctly.  It is total BS.

\"ist2_584876-rejected-denied-stamps-vector\" This may seem like a benign little problem – which it was in this case – but it can be very costly to doctors and patients.  A man called our office furious because one of our physicians did a physical on him and ordered a lipid profile, PSA, and blood sugar, but the insurer would not pay for these lab tests.  The problem?  He used the code for \”Well Adult Exam\” (which is what he performed) instead of \”Screening for Lipid Disorders,\” \”Screening for Prostate Cancer,\” and \”Screening for Diabetes.\”  Resubmitted, these charges went through without problem.

Another patient called because the colonoscopy I ordered was not being covered (but applied to her deductible) because I used (correctly) the diagnosis code: \”blood in stool.\”  If, however, I changed the code to \”Screening for colon cancer,\” the procedure was paid for 100%.  She is 50 and had never had a colonoscopy and so was due for a screening test anyhow.  But I had given her cards to check her stool for blood, which came back positive – a finding suggesting higher risk for colon cancer.  I had followed the rules.  Silly me.

To make matters worse, the numbers associated with the diagnoses (the ICD-9 Codes) are changed on a regular basis.  This means that the Hypertension code (ICD-401) is no longer paid for, but the code ICD-401.0 is paid for.  We generally find out about these through rejections by the insurers – the changes are too numerous for us to remember.

Here\’s another mystery: If I order a rapid strep test that comes back positive, I can\’t say the strep test was done for the diagnosis of Strep Throat (ICD-034.0) or it won\’t get paid for.  If, however, I use the diagnosis of Pharyngitis (ICD-462) it is paid for.  The \”logic\” of this is that if you know the patient has strep, why would you do a strep test?  This makes no sense, because the only way we can make the diagnosis in our office is to do the test.  This \”logic\” holds for EKG\’s, and Lab work done in the office.  You cannot use the test results to justify the test itself.

A physician friend ordered a PSA mistakenly on a man under 40.  The test came back positive, and the man did, in fact, have cancer.  The insurance company refused to pay for the PSA test, but they did pay for the treatment of the cancer.

A last area of insanity comes into play in a common pediatric situation.  Infants with fevers are often admitted to the hospital to \”rule out sepsis.\”  I certainly don\’t want to wait for sepsis to happen (bacteria in the blood causing life-threatening consequences) before I admit the child, so end up admitting many children who don\’t end up having sepsis (thankfully).  I cannot admit the child with a diagnosis of fever, as this is not a hospital-worthy diagnosis in the eyes of the payers (although it actually is a great reason for admitting very young infants).  I also cannot use the diagnosis \”rule out sepsis\” – which is the sole reason for admitting the child.  If I\’m lucky, one of the lab tests will come back abnormal enough (high white blood cell count, elevated CRP) that I can use the code for that abnormal lab finding.   But banish the thought that all the labs are normal and I did the work-up.  I should have known they would come back negative and not admitted the child in the first place.

\"labyrinth-advance-poster-c10120884\"There are many times when I suspect disease and don\’t find it.  This is what good doctors do.  But beware!  If you do what is right, you still can get caught in the coding labyrinth and become hopelessly lost.

The cynical among us suspect that insurers are not rushing to fix this confusion.  When we submit the wrong code due to confusion or just lunacy, it means they don\’t have to pay.  It is our problem, not theirs.  There is no financial motivation on their part to fix this problem.

It would be nice if doctors were paid for doing a good job.  But being a good doctor is not enough; to get paid, you need to decode the codes.  And to decode the codes, you have to learn the mysterious language of idiots.

32 thoughts on “Decoding Coding”

  1. Excellent post! It clearly illustrates how healthcare is hurt by the stranglehold that insurance companies have over the system. They are in charge of the purse strings, thus they make the rules. (and all plans have different rules) I don’t think patients realize how frustrating this is for doctors…and how close many doctors are to throwing up their hands and refusing to take insurance altogether.

  2. Excellent post! It clearly illustrates how healthcare is hurt by the stranglehold that insurance companies have over the system. They are in charge of the purse strings, thus they make the rules. (and all plans have different rules) I don’t think patients realize how frustrating this is for doctors…and how close many doctors are to throwing up their hands and refusing to take insurance altogether.

  3. Thank you for writing this post. Coding is so frustrating for all the reasons you give, esp if you try to do what is right.

  4. Thank you for writing this post. Coding is so frustrating for all the reasons you give, esp if you try to do what is right.

  5. It’s hard to be a patient in this regard too. I needed physical therapy. So I called my insurance company to see how much it would cost and what they would pay. They said they needed a diagnosis code. I called the physical therapy department and told them I needed a diagnosis code in order to find out what I would be paying. They said since they haven’t seen me yet they don’t know what the diagnosis code is. I went in there not knowing if I’d be paying $15 or $150.
    The first day I show up the receptionist says “You have a $15 copay.” I said, how do you know that? She said she called the insurance company. How come it was so easy for her to figure it out, but no one would tell me anything. It’s so frustrating!

  6. It’s hard to be a patient in this regard too. I needed physical therapy. So I called my insurance company to see how much it would cost and what they would pay. They said they needed a diagnosis code. I called the physical therapy department and told them I needed a diagnosis code in order to find out what I would be paying. They said since they haven’t seen me yet they don’t know what the diagnosis code is. I went in there not knowing if I’d be paying $15 or $150.
    The first day I show up the receptionist says “You have a $15 copay.” I said, how do you know that? She said she called the insurance company. How come it was so easy for her to figure it out, but no one would tell me anything. It’s so frustrating!

  7. [Comic Book Guy] BEST POST EVER!!! [/end]
    I can see just how bad a system this is, and I’m not American, or an HCP. At minimum, the system needs to be universal, and one or both of comprehensive and simplified.

    What is the function of an insurance company? To take your money, but never actually make a payment! 😉 Anyone else thinking of “The Incredibles” now?

  8. [Comic Book Guy] BEST POST EVER!!! [/end]
    I can see just how bad a system this is, and I’m not American, or an HCP. At minimum, the system needs to be universal, and one or both of comprehensive and simplified.

    What is the function of an insurance company? To take your money, but never actually make a payment! 😉 Anyone else thinking of “The Incredibles” now?

  9. This is covert rationing at its finest. I find it funny that the insurance market is the party responsible for this, when we all “know” it is the government that is responsible for all the beaureaucratic horror in the world.

  10. This is covert rationing at its finest. I find it funny that the insurance market is the party responsible for this, when we all “know” it is the government that is responsible for all the beaureaucratic horror in the world.

  11. This is incredibly frustrating to the patient as well. I have a very complex medical history, and figuring out which thing is causing what is difficult, and probably gives my doctors a huge headache to figure out. I did not realize you could change the code and then possibly get it covered (obviously only if it is still truthful when you change it). I usually just pay the bill after I call and try to understand why something wasn’t covered. That is costly, and if it is possible to try another code would it be rude/pushy of me to ask my doctor to try?

  12. This is incredibly frustrating to the patient as well. I have a very complex medical history, and figuring out which thing is causing what is difficult, and probably gives my doctors a huge headache to figure out. I did not realize you could change the code and then possibly get it covered (obviously only if it is still truthful when you change it). I usually just pay the bill after I call and try to understand why something wasn’t covered. That is costly, and if it is possible to try another code would it be rude/pushy of me to ask my doctor to try?

  13. I hate it that we all suffer. As a doctor, I work really hard at trying to get the right code – most of it for the sake of the patient. The woman with the colonoscopy called me and I changed the code – not because it made any difference to me. I am just glad that she knew. How many patients out there are getting slammed without need? It is a fiasco.

  14. I hate it that we all suffer. As a doctor, I work really hard at trying to get the right code – most of it for the sake of the patient. The woman with the colonoscopy called me and I changed the code – not because it made any difference to me. I am just glad that she knew. How many patients out there are getting slammed without need? It is a fiasco.

  15. Hey…even though I’m an outpatient coder, I absolutely agree with your last statement about “the mysterious language of idiots”. We (the coders) aren’t the idiots in question, of course; hopefully you’re referring to the insurance companies who won’t pay anyone unless the codes are exactly right. It’s a total nuisance of a system, and there are actually some occasions when I feel a bit badly about having to ask the provider sometimes several questions to make sure the documentation is consistent enough to pull the “proper” codes from.
    I’ve even had situations like you describe with the “rule out” concept; often providers don’t understand the convoluted, crazy rules (most devised by Medicare and its relatives) and they ask us why certain codes can’t be used or why they always need a definitive diagnosis. It’s nuts, for sure! (But at least you talk about it with a much nicer tone than some other doc bloggers I’ve seen!) It’s all just a symptom of a broken system, IMHO.

  16. Hey…even though I’m an outpatient coder, I absolutely agree with your last statement about “the mysterious language of idiots”. We (the coders) aren’t the idiots in question, of course; hopefully you’re referring to the insurance companies who won’t pay anyone unless the codes are exactly right. It’s a total nuisance of a system, and there are actually some occasions when I feel a bit badly about having to ask the provider sometimes several questions to make sure the documentation is consistent enough to pull the “proper” codes from.
    I’ve even had situations like you describe with the “rule out” concept; often providers don’t understand the convoluted, crazy rules (most devised by Medicare and its relatives) and they ask us why certain codes can’t be used or why they always need a definitive diagnosis. It’s nuts, for sure! (But at least you talk about it with a much nicer tone than some other doc bloggers I’ve seen!) It’s all just a symptom of a broken system, IMHO.

  17. Jeez, even an Anesthesiologist like me knows a case of Hidadrenitis Supporativa when he sees it….Then you take out the Code Bookie Thingie, and look it up, just like it was a naughty word, which I usually end up yelling, cause I always pick up the PROCEDURE Coding book by mistake….shouldn’t I pick the right one %50 of the time?

  18. Jeez, even an Anesthesiologist like me knows a case of Hidadrenitis Supporativa when he sees it….Then you take out the Code Bookie Thingie, and look it up, just like it was a naughty word, which I usually end up yelling, cause I always pick up the PROCEDURE Coding book by mistake….shouldn’t I pick the right one %50 of the time?

  19. You have addressed one of my biggest hassles and the sadness is that I get to face it over and over each day. I do not have an EHR that makes it easy so I am constantly stopping my work flow to look up codes in the HUGE book and flip through trying to find the code for Vitamin D deficiency or blood in stool or thousands of symptoms that patients present with. Yes, I have a cheat sheet but finding what I need is time consuming and frustrating beyond belief. It is Byzantine and wasteful and is one of the factors that is driving primary care into concierge practices (where there is no coding) and driving medical students away from primary care.
    You are also correct that patients suffer in their pocketbook as denials for coverage of legitimate claims increase. Patients can’t begin to understand the complexity and we do try and change the codes when we find out about it, but most of the time it is just another free ride for the insurer.

  20. You have addressed one of my biggest hassles and the sadness is that I get to face it over and over each day. I do not have an EHR that makes it easy so I am constantly stopping my work flow to look up codes in the HUGE book and flip through trying to find the code for Vitamin D deficiency or blood in stool or thousands of symptoms that patients present with. Yes, I have a cheat sheet but finding what I need is time consuming and frustrating beyond belief. It is Byzantine and wasteful and is one of the factors that is driving primary care into concierge practices (where there is no coding) and driving medical students away from primary care.
    You are also correct that patients suffer in their pocketbook as denials for coverage of legitimate claims increase. Patients can’t begin to understand the complexity and we do try and change the codes when we find out about it, but most of the time it is just another free ride for the insurer.

  21. I think everyone (well except maybe people who have shares in insurance companies 😉 ) is singing off the same sheet here!

  22. I think everyone (well except maybe people who have shares in insurance companies 😉 ) is singing off the same sheet here!

  23. Annoying and expensive for the patient as well. There’s a cholesterol test my doc routinely orders, and my insurance company routinely says it’s not covered because it’s “not coded right.” They won’t tell me how it’s coded, or what code would work. My doctor says it should be paid (and uses the results to fine tune my meds), but…how to get the two together? The insurance company wants my doctor to call. I can’t seem to get the attention of the office manager to get anything done about it.
    So the lab charges $150 because they know the insurance company will only pay a small portion of that. Since it’s denied, I end up on the hook for the full $150.

    What a waste of time and money.

  24. Annoying and expensive for the patient as well. There’s a cholesterol test my doc routinely orders, and my insurance company routinely says it’s not covered because it’s “not coded right.” They won’t tell me how it’s coded, or what code would work. My doctor says it should be paid (and uses the results to fine tune my meds), but…how to get the two together? The insurance company wants my doctor to call. I can’t seem to get the attention of the office manager to get anything done about it.
    So the lab charges $150 because they know the insurance company will only pay a small portion of that. Since it’s denied, I end up on the hook for the full $150.

    What a waste of time and money.

  25. Well, they’re either providing the wrong CPT code for the test itself (a glitch in the system, perhaps) or the wrong associated diagnosis code (which should be something like hyperlipidemia or hypercholesterolemia). It sounds to me like you (as the pt required to pay) are getting the screws put to you by someone in the system (don’t know if it might be the computer people, the business people or whoever) who doesn’t care what happens. It’s not really the doc’s fault, and it’s not the insurance company’s fault, either; but they need to find a reasonable solution to this problem so it doesn’t keep recurring and giving patients like you a big old headache and/or resulting in unnecessary out of pocket expense. Does your doc’s office have any coders? If they do, perhaps they’d be the people to help fix this problem in conjunction with the docs and the insurance company. Just a thought.

  26. Well, they’re either providing the wrong CPT code for the test itself (a glitch in the system, perhaps) or the wrong associated diagnosis code (which should be something like hyperlipidemia or hypercholesterolemia). It sounds to me like you (as the pt required to pay) are getting the screws put to you by someone in the system (don’t know if it might be the computer people, the business people or whoever) who doesn’t care what happens. It’s not really the doc’s fault, and it’s not the insurance company’s fault, either; but they need to find a reasonable solution to this problem so it doesn’t keep recurring and giving patients like you a big old headache and/or resulting in unnecessary out of pocket expense. Does your doc’s office have any coders? If they do, perhaps they’d be the people to help fix this problem in conjunction with the docs and the insurance company. Just a thought.

  27. Who invented such a silly system!
    It probably started up trying to facilitate the already cumbersome paperwork and for statistical purpose too. How on Earth has it evolved to today’s sorry shape?…. Frustrating.

    Does anyone know how European docs “code”/designate diagnosis and treatment?

  28. Who invented such a silly system!
    It probably started up trying to facilitate the already cumbersome paperwork and for statistical purpose too. How on Earth has it evolved to today’s sorry shape?…. Frustrating.

    Does anyone know how European docs “code”/designate diagnosis and treatment?

  29. Not me; I don’t have that sort of interface with the system, and don’t know anyone that does well enough to ask them to come and join us.

  30. Not me; I don’t have that sort of interface with the system, and don’t know anyone that does well enough to ask them to come and join us.

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