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Decoding Your Doctor’s Medical Coding

As a healthcare advocate and a former Affordable Care Act navigator I consider myself pretty savvy when it comes to navigating the American medical billing system. Still, that didn’t prevent the confusion I experienced at my husband’s recent annual well care visit.

Early on in the visit, the electrocardiogram machine was pushed into the room. We were assured that the cost of the test was included at no charge to us as test were being administered. Once all of his vitals were taken, the doctor entered the room to discuss his medication. After reviewing his blood pressure the doctor said “cut one of your pills in half” and “you are doing fine.”

Three weeks later a bill arrives with a charge for the electrocardiogram at a billed rate of $27.00, discounted to $17.15 and another charge for an office/op visit charged at $114.00, but discounted to $30.61.

Fortunately, the Explanation of Benefits (EOB) from the insurance company had just arrived the day before. The visit was billed as an annual wellness visit (code G0438) at $270, discounted to $148.39 and paid for by the insurance company. The EOB also showed an additional billed amount of $114 for office or other patient (code 99213) in addition to the wellness visit.

After being on the phone for 45 minutes with the doctor’s office I learned that code 99213 code was billed for the “cut your pill in half” statement. After another 30 minute phone call with the insurance company I found out that the electrocardiogram was billed with the wrong code. “Call the doctor’s office and have them resubmit with the correct code” said the insurance company. “Which code is that?” I replied. The insurance company’s representative didn’t know and actually said that whatever codes a doctor puts on a bill, the insurance company will pay at the negotiated discounted rate. However, you as the patient have no idea what these (expletive deleted) codes are.

So what can you do? Before leaving the doctor’s office ask for a summary of your appointment detailing the services received and their associated CPT (Current Procedural Terminology) codes. You have the right to this information. This allows you to match up the codes on the bill and the EOB and make sure you are billed for the correct procedures. Needless to say that at a $2,286 premium per month with a $5,000 deductible you, the customer, should not have to do all this work. While this is true, make it a point to ask for this information after you leave your appointment to make sure you are armed with the knowledge you need to take charge of your health.

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