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There are numerous systems developed within the medical community in order to maintain continuity and consistency amongst physicians and other health care providers. This includes insurance companies.
Two of these systems are the CPT (Common Procedure Terminology) coding and ICD-9 (diagnostic/diagnosis) coding. The CPT coding involves your office visits, procedures whether in the doctor’s office or in the hospital including surgical and any other type of visit/procedure you may have.
Diagnosis coding pertains to your specific diagnosis. While there are some ICD-9 codes which are labeled pertaining to a specific body part, there are "nonspecific" codes which can be used. Frankly, this only adds to confusion and sometimes insurance denials so it is important that physicians or more specifically their billing department codes correctly.
Coding errors as they are routinely called occur more often than they should. When my daughter was a toddler, she had to have tubes placed in her ears because of recurrent ear infections. This was done for both ears.
When I received the EOB (Explanation of Benefits) from the insurance company they had only paid about $650 of a $1500 bill. Because of my many years in Practice Administration and overseeing billing and coding, I quickly recognized that the surgeon's office had incorrectly coded the procedure. While they did have the correct code for that procedure, what they failed to add was the "52" modifier to the end of the code indicating that this was a bilateral procedure.
I contacted the surgeon’s office, had the claim resubmitted with the correct code, and the insurance paid another $650. Had I not picked up on this coding error, I would have been responsible to the physician for the remaining balance of $850 instead of $200. Many people don't question these things by calling their insurance company and often just pay the balances they are billed.
Sometimes, more significant situations can occur with errors in diagnosis coding. Individuals can be declined for life insurance policies because a prior doctor's visit was coded as having congestive heart failure instead of congested sinuses.