Medical coding is often difficult to understand, requiring additional research into what exactly each procedure code is referring to. In an article published by the New York Times, journalist Elisabeth Rosenthal explores the difficulties of deciphering medical bills, and its effects on both patients and businesses.
CPT (Current Procedural Terminology) codes are a collection of standardized five-digit codes used to report medical services under most insurance programs. Law offices aim to ensure that a client's medical treatment is reported correctly by submitting these codes and medical records to the insurance adjuster on file, however the ambiguity of medical codes leaves businesses looking for answers. Ms. Rosenthal states that the reason for this confusion is due to a lack of standardization. Although CPT codes are kept in a database maintained by the American Medical Association (AMA), the database is subscriber-only, and medical bills may vary based on a particular facility or hospital. Billing statements do not adequately explain the meaning of each billed code, thus forcing patients and businesses to decode statements such as "HC CT GUIDED NEEDLE PLCMNT ASP BIOP."
According to Christina LaMontagne, vice president of a financial services company that provides medical bill audits, the standardization of medical coding leaves a lot to be desired. She suggests the American Medical Association should offer more "user-friendly" interpretations which would greatly help both insurance adjusters and law offices in the negotiation process. Additional industry standards are needed for patient information, as well, as there is no clause in the HIPAA Guidelines (originally passed in the Health Insurance Portability and Accountability Act of 1996) involving a patient's right to receive clarification of billing statements, which are often vague or inaccurate.
Ms. LaMontagne states that while previous generations have tolerated the CPT code system, future generations may grow frustrated with the hours of research required to find an explanation of a code in layman's terms. As the 2016 CPT Coding update approaches, many look forward to the passing of additional legislation requiring proper industry standards for medical billing and improved descriptions that do not require thorough searching.
At Kaufman Law, we see certain industry trends that are beyond troubling. Many of our clients purchase MedPay coverage. This is the insurance coverage that allows the insured injured person to pay for their own medical treatment or reimburse themselves for deductible and copay funds. These unpaid medical bills can become outrageously expensive for injured persons. Hospitals will pursue these debts against the injured person. MedPay is designed to be trouble free, however, certain insurance companies, like USAA and State Farm, go to outrageous lengths to find hospital coding "errors" in order to deny or very seriously delay payment of MedPay claims. The cost of requiring automobile insurance companies to pay their medical claims is expensive for the claimant by design. They often use their own codes to "explain" their reasons for their failure to pay claims, but the reasons for denial are usually cryptic. The insurance commissioners of each state are the correct entity to pressure the insurers to remedy this process, but because they solicit political donations from these companies, they won't require honest or transparent claims handling. Until our state government officials demand fairness to the public, the practice will continue to make the lives of injured claimants miserable.