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

***

For further reading:

 

Requesting Test Results

Some places make it easier than others to get copies of your test results (and other medical records).

At my PCP’s office, the first time my doctor went over lab results in detail, he offered, “Would you like a copy of this?”  At the end of the appointment he handed that page to the MA and asked her to make a copy for me.  Another time my husband had some abnormal labs and the nurse who phoned offered to mail him a copy of the results.

My PCP makes it easy – it’s the culture in his office.  When I wanted more information and asked the front desk how to get copies, the receptionist grabbed my chart and said, “I can make copies for you right now.  What do you need?”  That’s for just one or two sheets of paper.  When I asked for a whole bunch of copies, I was asked to sign a release.  My doctor keeps track of stuff like that.

I appreciate his approach a LOT because it hasn’t always been so easy.

When we moved, finding a new pediatrician for my kids was difficult.  The first doctor didn’t work out.  When we left that practice, it was nearly impossible to get my kids’ records.  First I phoned and asked, but nothing happened.  Next I completed the records request form for the new doctor and his office sent it to the old doc.  Nothing happened.  I phoned again and was told that I’d have to fill out the old doc’s records release form.  Okay… Still nothing.  I phoned one last time to receive more empty promises.

Finally I wrote a letter citing specific dates that I’d previously asked for my kids’ records and closed with, “It isn’t supposed to be this hard!  What steps do I need to take to have you release these records that my children’s pediatrician has requested and I have a legal right to obtain?”  This was misconstrued as a threat of legal action, and the records were copied and sent to the new pediatrician promptly.

***

According to the Health Insurance Portability and Accountability Act (HIPAA), patients in the United States are legally entitled to see their medical records.  Patients are also entitled to copies of that record, including test results.  This is not either/or.  We’re allowed both a peek at the chart, and a copy.

The doctor doesn’t have to give the copies away, though.  It takes time to pull a chart, find the requested pages, make copies, then re-assemble the chart.  Paper and ink for the copy machine cost money.  Postage adds up.  Doctors are allowed to charge a fee to cover the costs associated with getting copies for patients.  One of my first jobs involved quite a bit of filing (which led to my speedy decision to attend college), so I am strongly in favor of making people pay reasonable costs associated with all this paperwork.

Just to confuse matters, in addition to HIPAA, every state has extra laws surrounding the subject of patient-access to medical records.

Confused yet?  There are some circumstances in which doctors can deny a patient’s request – for instance if the doctor believes that the patient would cause harm (to self or another) upon learning the information in question.  There are ways around that, though.  Reference the above links if you need more information.

If a simple request to your doctor doesn’t yield the desired results, check out Trisha Torrey’s How to Request Your Medical Records for some good tips.

HTH

New Rx

Pre-Approval

On my planet, if there were such a thing as prior authorization requirements (which is highly doubtful – on my planet we would just let doctors practice medicine to the best of their judgement) – I digress – if … then the rheumy’s office would phone/fax the insurance company to notify them of the new med, and away we’d go.

Sav-Rx tells me that it can take them up to 72 hours to approve a biologic.  So why does my rheumy says it might take a week?

The doctor writes the prescription and the patient takes the Rx to the pharmacy – just like normal.  BUT when the pharmacist goes to fill some prescriptions, the insurance company says “gotta have pre-approval for that.”  The pharmacy then sends a fax to the doctor’s office, where they are expecting the fax.  The nurse will be sure to complete the required paperwork and put it on the doctor’s stack of papers to sign.  Those papers will be signed the following morning and sent on their merry way.

Does this seem a little convoluted to anyone else?  Why can’t (spell-check thinks this shouldn’t have an apostrophe!) the doctor’s staff fax directly to the insurer when the prescription is written?  Why does the pharmacy have to be in the middle of all this?

Anyhow, yesterday I delivered the Rx to the pharmacy – day one.  In theory the pharmacy faxed paperwork to the doctor yesterday.  This morning my rheumy will sign everything so that her nurse can return it to the pharmacy – day two.  At some point during the chaos at the pharmacy, those papers will magically be transmitted to the insurance company.  If they’re really busy, or if the fax isn’t sent until evening, the insurer might not see the info until tomorrow.  Not until they log receipt of the paperwork does Sav-Rx start their 72 hour clock.

On Planet WarmSocks, three days would be counted {Wed-Thurs-Fri}.  On Planet Earth, {WednesdayThursday, Friday could be day one, SaturdaySunday, Monday is day two, Tuesday is day three}.  Which means it could be Tuesday before the pharmacy receives approval, and Wednesday before my prescription is ready to be picked up.

Samples

My rheumatologist gives the initial dose in her office (as a sample), and that would have occurred yesterday had I not been a little past due on one of my vaccines.  I’ll be back in town today for my tetanus shot (it’s been… shall we just say a few years more than ideal – oops).  I could have gone ahead with the Enbrel yesterday, but the tetanus shot is likely to be more effective alone so I’ll head back to town again on Monday for my first Enbrel injection.

Increased Risk of Infection

TNF-inhibitor warnings all say phone your doctor if…  Which doctor?! 
My PCP and rheumatologist both say, “either one” is fine.  Rheumy thought about it a little more and clarified:

  • routine cold/sniffles, no need to phone (but skip Enbrel shot that week)
  • fever/cough – call PCP (skip Enbrel)
  • hacking up phlegm – call rheumy and she’ll probably want a chest x-rays (skip Enbrel)
  • minor cut – no need to phone but wash it really well

Kids

I don’t recall telling the rheumatologist that my kids are homeschooled, but she must have discovered this somehow.  Yesterday, after our discussion of when/whom to call if I get sick, the doctor commented that “less exposure to illness” is one advantage to my kids not going to school.  True statement; most hser’s acknowledge this.  And my doctor got all flustered!  “I don’t mean to imply that they’re not getting an education… what I meant was…”  It’s okay.  Really.  My freshman is studying algebra and biology; my sophomore is studying geometry and chemistry (among other things).  I am confident that their education is appropriate and don’t get offended by well-intentioned remarks.  The kids aren’t exactly kept in a closet, but they don’t get exposed to all the germs they would inhale if they were in a classroom every day.

Normally I try not to take the kids with me, but the boys tagged along again yesterday and sat in the waiting room with a couple schoolbooks so that the day wasn’t a complete loss to them.  We have rules for when that occurs.  Things like be quiet, and don’t annoy the staff or patients, and I expect this assignment to be finished when I come out, and if the waiting room fills up, give your seat to a patient.  People always comment on how well-behaved the kids are, so I assume they really are behaving.  When they finish their assignments, they get to use their sudoku books.  This made people curious and my boys had to explain sudoku puzzles to everyone.  If the patients at that office are typical, I’m thinking doctors might like to add a few sudoku puzzle books w/ pencil to the magazine racks in the waiting area.

I received my fourth cortisone shot since July yesterday – pushing the envelope here.
Monday I
‘ll begin Enbrel.