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. This is a stretch between these two diagnoses, but I think you understand my point.
Cancer policies are common now. Years ago there were no such policies. These can be financially life-saving if an individual has the unfortunate experience of being diagnosed with cancer after having purchased one of these policies.
However some patients with carcinoma in situ which is the same as a Stage 0 cancer are being denied their benefits under these cancer policies. This comes from a confusion between the diagnosis of "IN3" intraepithelial neoplasia Grade 3 and carcinoma in situ or CIS.
Intraepithelial neoplasia can be used when relating to the cervix (CIN), vagina (VaIN), vulva (VIN) or anus (AIN). There is no difference between a diagnosis of, for example, a CIN3 and a carcinoma in situ. As I mentioned above regarding coding, individuals who are being denied their benefits under these policies need to get with their physicians and get this corrected.
Your physician needs to correct and send follow-up to your insurance company (health insurance) and cancer insurance company and utilize the correct code, which in the case of the cervix, is 233.1.
There is no reason why coding errors should be the cause of individuals being denied benefits they so deserve, especially, in my opinion, when dealing with cancer.
Adams, Diane L., et al. "Addressing medical coding and billing part II: a strategy for achieving compliance. A risk management approach for reducing coding and billing errors." Every Patient's Advocate Web September 15, 2011 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2594405/
Tarrey,Trisha.”How a Wrong Diagnosis Code Effect a Patient.” Every Patient’s Advocate August 2009. Web September 15, 2011
Reviewed September 15, 2011
by Michele Blacksberg RN
Edited by Jody Smith