As a small private practitioner in speech-language pathology, I find that most people are very confused about their health insurance plan. People know that they are paying a lot of money for something every month, but few people understand all of what is and is not covered under their plan. Even fewer consumers understand how the health plan determines whether or not they will pay a health care claim once it is submitted. In an effort to help educate the public about this important topic, I would like to start by discussing the codes involved in submitting a medical claim.
You’ve probably all seen those commercials on TV, encouraging you to join the “exciting” and growing field of medical coding. This is the field of individuals who assign the underlying codes to the claims that are being submitted to the insurance companies. The insurance companies use these codes to determine if you are covered for the service you received. So, medical coding professionals certainly are important. I’m not as certain about how exciting it may be…
Primarily, there are two sets of codes to be concerned about: diagnosis codes (ICD-9 codes) and procedure codes (CPT codes). There are others, but for the sake of this article, I will focus on these two.
These are the “International Classification of Diseases, 9th edition” codes. Also known as “diagnosis codes”, the ICD-9 code is what informs the insurance company about what disorder is being treated by your medical professional. For example, in my field the code 478.5 means that someone has a bump on their vocal folds. The code 476.0 means that a person has chronic laryngitis. It is possible that more that one code applies to your situation. That’s fine, because every medical claim can accept more than one code. Very soon, these codes will be upgraded to ICD-10 code, which are already in use in Europe and much of the rest of the world, but the principle will remain the same.
“Common Procedural Terminology” codes are the codes that tell the insurance company what you did with the patient. For example, 92506 is a speech therapy evaluation; 92507 is individual speech therapy treatment. Once again, a claim may have more than one code, if more than one thing was done with the patient at that visit.
How the Codes Are Used
Each insurance claim is submitted to the insurance company with the above mentioned codes. The codes are fed into a computer where it is compared to the information about what your plan covers, whether you have a deductible, how much of that deductible you’ve spent so far, etc. If the disorder and the procedure code are covered, then the medical professional gets the fee that was agreed upon with the insurance company. If it is not covered, then the medical professional doesn’t get paid and usually the patient needs to pay the balance.
Shouldn’t I Know This Ahead of Time?
In my opinion, it should be easy to log into an insurance company web site, as a patient or care provider, and plug in an ICD-9 code and CPT code and find out whether or not it is covered. Unfortunately, this is not the case. Usually I find that the representatives at the insurance company will not commit to disclosing whether or not a particular item is covered. They always want an out. Given the impossibility of getting the information ahead of time, people sometimes get surprise bills for things they thought would be covered.
I hope this summary is helpful in allowing you to be more informed as a health care consumer.