Valid and Billable Codes: a closer look at what that means

Valid and Billable Codes

Last post I talked about what a CPT code was and a diagnosis code.

CPT – what we are doing. Diagnosis Code – why we are doing it.

Another small piece here for you.

What is a valid and billable code? And why is that important? And why did I still get an outrageous bill even though the DR office said the code was covered?

Each insurance contract is different. My work contract at the last facility I was at did not cover gastric bypass or lap-band surgery in the employers contract with the insurance carrier. However, more then one friend and I had a discussion about working for ‘so and so’ because they did cover it.

Because of HIPAA, I can talk about myself, but I can’t talk about other people. I dislike talking about my medical issues, but legally I can because I am the owner of that information. When I was made God said – lets make her struggle with her weight and have about every messed up female problem possible without getting a cancer diagnosis, it will build character! Thank you…

Back to the discussion at hand – Gastric bypass (another term you may have heard is stomach stapling). It’s an easy one to discuss because a lot of group contracts won’t cover it.

There are a couple different procedures. CPT 43842 & 43843 is a banded bypass (Lap-band). 43846 & 43847 are open up like the last scene in Braveheart and have a viewing kind of operation. 43644 and 43645 are Laparoscopic (little tiny holes and a video camera). Taking the last two: The Braveheart version has a much longer recovery time and would be much costlier because it is more invasive than the camera version.

Okay – Now we have to divert for a moment and talk about a couple things –

NPI (National Provider ID) is a number assigned to a group or individual

Tax ID is just that, a Tax ID

A doctor’s office bills PROFESSIONAL charges

The hospital or surgery center is the FACILITIES charges

You can have a procedure in an: office/clinic, Ambulatory Surgery Center (ASC) or a Hospital/Facility.

You can have a service done as outpatient – 23 hours or less.

You might need to be Inpatient – 24 hours or more.

Now – lets look at the CPT code 43846 & 43847 – Braveheart Gastric Bypass!

Will there be a doctor – yes. In fact there will be a lot of doctors.

Your surgeon will send out a Professional bill for doing the surgery – NPI number 1

The hospitalists or attending doctors that take care of you for your recovery will also send a Professional charge for their services – NPI number 2

The anesthesiologist will also send out a bill with Professional charges – NPI number 3

Will you be in a hospital for a couple days? I hope so

The hospital or Facility will send a bill, the largest bill, like 80% of your bill – NPI number 4

Each one provider looks up information using our own NPI number and Tax ID combination.

The insurance carrier will look at the code using the following filters created by the NPI/Tax ID combination:

Is the NPI/Tax ID in network

Is the NPI/Tax ID for a preferred or contracted provider

Is the NPI/Tax ID able to perform this service

Is it a valid code, is it an actual CPT Code

And

Is the CPT billable by that NPI/Tax ID combination for the PATIENTS group as a covered service

Now in the case of Braveheart Gastric Bypass!, there are a lot of things that go into this.

If I would have called as the Facility to review benefits for myself under my old insurance plan:

Me - Hello, I would like to know if CPT 43846 and 43847 require prior auth as an inpatient service and if they are valid and billable codes.

Rep – CPT 43846 and 43847 are valid codes, but not a benefit under this groups plan. All inpatient services require prior authorization.

If I worked for ‘so and so’ company that covers gastric bypass the conversation would have gone like this:

Me – Hello, I would like to know it CPT 43846 and 43847 require prior auth as an inpatient service and if they are valid and billable codes?

New Rep – Cpt 43846 and 43847 are valid and billable codes and do not require prior auth nor does the inpatient stay under this patients plan.

Experienced Rep – CPT 43846 and 43847, do you have a diagnosis code for this procedure?

Here’s the thing – These CPT’s would require one of the diagnosis to be that the person having the procedure had a BMI over 40. The more experienced insurance carry representative would know to ask. The more experienced hospital financial clearance team member would also know to ask.

One more complicated thing about valid and billable codes –

There are things that are billable for the doctor that are not billable by a facility or ambulatory surgery center.

If you go to the doctors office and have one really bad toenail that needs professional attention – the doctor will clip your toenail (CPT 11720 – debridement) and the office visit (CPT 99213).

If the doctor calls the insurance company – under the Professional NPI/Tax ID combination – they will be told it is a covered benefit.

If the Facility calls about CPT 11720, the Facility NPI/Tax ID may be told it is NOT a covered benefit. Because you don’t need your toes clipped in a hospital at $187 dollars a minute for OR time. If you do – there better be a whole host of supporting diagnosis codes.

And that’s the complicated part. A doctor using their NPI/Tax ID number maybe contracted with insurance carriers and asking if services will be covered for them. They get told as it relates to the Professional NPI/Tax ID combination. The Facility can get a completely different answer and may not even not even be contracted with the insurance carrier of the patient using the Facility NPI/Tax ID.

The more specialized the doctor, the more likely their privileges are allowed all over the place while the facility may have less of a foot print.

This applies to Medi-share, workers comp, Jones act and even travel insurances. Each will have covered services, non-covered services and things you have to do to get your medical bill paid. Medicare – For – All will not be any different. I review codes for Medicare now and have to tell people that a service is not covered. A person on Medicare can not have breast reconstructive surgery paid unless it is related to specific cancer diagnoses.

While this is really complicated, let’s say you need to have a surgery, with the information above I feel you will have a more successful phone call to the insurance company to find out if the service is covered by your plan. Because you will know to be very specific about the CPT and Diagnosis code combination and place of service. Also, your estimates from different facilities will be closer to the real cost because you didn’t blow off that one CPT code you forgot to write down.

Next post will be on In Network, Out of Network and Tiered Network and how that can affect your out of pocket costs.