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: