Valid and Billable code. Wait, whats a Code?

Valid and Billable Code, what’s a code?

In New England I learned to say Soda, and in Washington State they make fun of me because I don’t say Pop. CPT and DX codes are ways of everyone talking about the same thing.

The CPT (Current Procedural Terminology) code is what we are doing to you.

Diagnosis code is why we are doing it. The most recent version we are using for diagnosis codes is the ICD-10 standard. (International Classification of Diseases – 10th revision) The USA is a bit behind on the DX, other countries update the revisions more often.

The CPT code is assigned to every procedure you could have. There is even a set of codes we called J-codes that had to do with injections. Getting a B12 shot, there is a J-code for that.

In a complicated series of procedures, like a heart cath, I would have to clear up to 10 codes for the one procedure. These are all the things that doctor would be doing, including the stent placed to help stabilized the arty wall. There are even codes for different types of stents. We would always ask if 92928 was covered, even if it was not on my list, because the drug eluding stent may not be covered, while other stents where. These specific stents would require an authorization.

I have had to call doctors offices and ask them “you have hip pain as a diagnosis, but your CPT is for a shoulder surgery?” I would not even bother calling the insurance company until I had clarification why the two were related. 99% of the time, it was just a data entry mistake.

Just remember, CPT is what we are doing and diagnosis are why we are doing it.

How does this affect your pocket book?

When getting an estimate, the software used will take the CPT code and will generate an estimate range based on the cost of surgeries over the past couple of years. I had to give an estimate, the difference in surgery with the 3 common CPT codes and those same CPT codes with a 4th less common CPT code was about $5,000.

When you get a bill and it is way more then expected, it may be a data entry error that did not include a diagnosis that goes with the CPT/procedures done.

I had fertility tests done in my early 40’s. When I received a bill for $450 I called the doctors office and asked why it was so high. The staff only entered one diagnosis that was not related to fertility. When they re-billed the procedure and labs with the additional two diagnosis’s, the bill dropped by $400 to just $50 out of pocket.

Next week I will move onto how we tell if a code is valid and billable.

For now – have fun – you can google anything and see what the CPT code is and you can even google the common diagnosis codes for that CPT code. Or you can google the diagnosis code. You can just put ‘dx code for back pain’. Dx is medical shorthand for diagnosis. There are even funny (at least to medical people) ICD-10 diagnosis codes. Z63.1, W61.43, W22.02 are interesting.