What Do All Those Numbers Mean?

Another batch of EOB’s arrived yesterday.  One piece of paper per patient per provider per appointment.  The stack of papers for last year’s medical visits is an inch high. 

Trying to decipher the details is quite a challenge.  Every single line item on every EOB has a secret code communicating something from the doctor to my insurer.

CPT Codes 

Usually I know, based on provider/date of service, enough to figure whether or not the right procedure was charged.  Once I went in for an ultrasound but was charged for a mammogram, so I check.  I’ve often wondered exactly what those numbers on my EOB and statement from the doctor mean.  The numbers vary.  An office visit is usually 99213 or 99214, but once was 99215; I’ve also seen 99244 and 99245 a few times. 

It turns out that these numbers are called Current Procedural Terminology codes, and the American Medical Association (AMA) holds a strictly-enforced copyright on them.  The AMA wants doctors/billing offices to buy a book (or subscribe online?) to obtain this information, and it is not available for free. 

Fortunately, there’s a small, short-term exception.  The AMA’s website has a search engine for looking up CPT codes.  I found it interesting to compare what I knew had happened at the doctor’s office to how the visits were coded – at least it was interesting until an error message popped up saying I’d reached the limit on how many codes I was allowed to look up! 

Also included is the dollar amount that medicare pays for those procedures, and it doesn’t take looking up very many codes to shed light on the reason behind the difficultly patients have in finding a doctor who accepts medicare.  But that’s a rabbit trail – back to the codes. 

As I suspected from reading my family’s EOB’s, 99391-99397 are codes for a routine checkup (well-child exams, school physicals for kids, annual check-ups for adults).  The specific code used depends on the age of the patient. 

There are (at least) two different codes for drawing blood, 36415-6, depending on whether they stick a needle in your vein or do a finger/heel/ear stick. 

There are (at least) four different codes for administering an immunization, 90471-4.  Which code is chosen depends on the number of vaccines given (single vs. multiple) and the method of delivery (shot vs. nasal/oral).  Extra codes are tacked on to indicate the specific type of vaccine. 

X-rays appear to begin with the digit “7″ and blood tests appear to begin with the digit “8″ – but that’s a guess based only on my EOB’s.  It’s entirely possible that there are other codes in the 70000′s and 80000′s that have nothing to do with x-rays and lab work.  Many of my x-ray CPT codes have -LT or -RT affixed, and I know you’re smart enough to figure that part out!

What I really wanted to know is the distinguishing factors between office visits that are coded 99213-5, and 99393-4.   I discovered that the first group of codes can only be used for established patients; the other two can be used for new patients as well as established ones.  In general, the higher the number, the more complex the problem is, the more detail needed in the history and exam, the longer the appointment,  and more expensive the visit: 

Click to enlarge

Knowing this, and comparing what I’ve learned against my record of what has taken place in the doctor’s exam room, I’m convinced that my PCP down-codes.

ICD-9 Codes

Another set of numbers is the International Statistical Classifications of Diseases, which are diagnosis codes.  Version 9 is currently being phased out, and version 10 is in the process of being phased in (and version 11 is in the works).

The doctor submits both a procedure code and a diagnosis code to your insurance campany – and the codes are supposed to be somewhat related.  Endoscopy for an ingrown toenail won’t work because they have nothing in common.

The reason we should care (and a good reason to periodically check your medical records) is that those diagnosis codes follow you forever.  When the doctor finally uses the ICD-9 code of 714.0, you have a chance of being approved for a biologic medication; you also have a good chance of being denied coverage based on a pre-existing condition if you ever need to change insurance companies. 

In the ICD-10 codes that are coming soon, RA has a different code depending on whether the person is seropositive (M05.x) or seronegative (M06.0).  I wonder what the coding will be when a person’s lab results change due to effectiveness of DMARDs

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4 thoughts on “What Do All Those Numbers Mean?

  1. Good god, that’s a full-time job in itself! Here in Canada, we don’t pay for medical visits directly, generally, unless something (rarely) isn’t covered. So no keeping track of anything like that.

    The only thing I’m keeping track of right now are my prescriptions, since 15% of the cost of them isn’t covered by my company’s health insurance coverage, and I’ll be able to claim that percentage on my taxes next year…

    Good luck with all the paperwork! :) Laurie

    • Many people don’t keep track. I know people who throw away their EOBs without even opening the envelope, and just assume that everything is right. I’ve gotten thousands of dollars back by knowing what those things say, so I check them pretty carefully.

  2. I have to admit my eyes just crossed, but I am overawed at your determination to not let the insurance companies steal your hard-earned money. It occurs to me that it’s a terrible shame that they put all this information into gobbletygook that’s incomprehensible to the average person, including the fact (as you pointed out) that they’re adding coding that will one day preclude a patient from receiving coverage at all. I’m sorry, but that just steams me, WarmSocks. I hope one day our country will provide medical care that’s more along Canada and Great Britain’s systems. They’re much more humane, aren’t they.

    • If your eyes are crossed then I must not have made it clear :( I think that if one had a list of the codes, it wouldn’t be so confusing because we’d be able to see exactly what the charge was for. It’s the cloak of secrecy that makes things so hard to figure out.

      The sad thing is that doctors have to spend so much time figuring out exactly which codes to use (or pay someone else just to be in charge of coding) and document very very carefully so an auditor can’t look at a patient’s chart and claim that the doctor overcharged. I’d rather have the doctor spend more time with me and less time writing in my chart. What’s so sad is that the codes weren’t developed for billing purposes; they were developed for people doing research. I look forward to a day when doctors can spend their time practicing medicine instead of on all the CYA documentation that they’re currently saddled with by the insurance industry.

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