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Medical coding in today’s world: A beginner’s primer to what Patient Advocates need to know

March 21st, 2018 | Posted in Advocacy 101, Insurance Coverage, Professional Skills

By Connie L. Zeller, BA, CPC, CCS-P, DecisionHealth Director of Education

The value of an advocate is to help patients understand the intricacies of healthcare.  Medical claims can be as confusing to patients as considering many treatment options.  Just as a patient advocate would navigate and explain the course of treatment for their patient, understanding medical claims can be equally important to the patient.

How many times have you reviewed your medical bill or explanation of benefits (EOB) and wondered why some of the charges were paid? Did you notice that some weren’t paid?  You may have also noticed that you weren’t charged the difference on some charges because of a write-off.  Do you know to interpret the codes on your EOB?

There was a time when I was the “go to” person in my family to decipher medical bills and EOBs.  As my grandparents aged, they would give me their bills, EOBs and any other paper that they considered relevant to their visit to the doctor’s office.  They knew that they had made a copayment at the office, but they didn’t know what the doctor was billing for and why it wasn’t paid.

It was up to me to figure out what they owed, or didn’t owe.  To start, I would look at the statement from the doctor’s billing agency to see if there was an amount due listed on the statement.  If not, I would look at the statement for the write-off amount and check the math to see that the charges, write off and copayment amounts lined up.  If there was an amount due, I would look at the charges and compare the billing statement with the EOB from their insurance company.

The EOB contains information that isn’t always listed on a billing statement. I had an advantage that others didn’t.  I worked for an insurance payer and knew how to interpret the codes on the EOB.

You don’t need to be a certified medical coder to effectively understand medical claims.  If you happen to be an advocate who helps patients with their medical claims, you need to know a few coding terms. Here are just a few:

EOB – I mentioned this earlier.  The Explanation of Benefits is provided by the insurance company.  Diagnosis and procedure codes are listed on the EOB.  Because of HIPAA regulations, insurance companies require that the patient log in to their personal account in order to see the codes.

ICD-10-CM – This is the diagnosis code.  Ask any medical coder about ICD-10-CM and you may be in for a long discussion.  The takeaway that you need to know is that these codes tell the insurance company the primary reason for a visit with a clinician and any secondary conditions that might be addressed during the same visit.  It’s the doctor’s responsibility to accurately capture and document the patient’s condition and the services performed during the visit.  If the information isn’t accurately captured, the insurance company may deny the claim for insufficient information and request medical records.

CPT® Code – Procedures are reported with CPT® codes.  The AMA (American Medical Association) publishes the CPT® codes annually.  This describes what takes place during the office visit.  The procedures are just as important as the diagnosis.  Was a blood sample taken from the patient?  Did the doctor spend 60 minutes discussing treatment options with the patient?  This information also needs to be accurately documented to determine the correct codes that are submitted to the payer.

Together the ICD-10-CM and CPT® codes tell a story about the patient and the reason the for the visit.  The EOB is the denouement of the office visit.  If an insurance company doesn’t cover services, there will be a denial code on the EOB.  These codes are called CARCs and RARCs, or Claim Adjustment Reason Codes and Remittance Advice Remark Codes; this is really getting into the weeds of medical coding.  What you need to know is that they specify the reason a diagnosis or procedure is paid or denied.

One of the most common mistakes that patients make is that they will pay a bill without reviewing the statement or the EOB.  It’s not uncommon for a patient to receive a statement before the insurance company has paid the claim. Even though claims are submitted and paid electronically, insurance companies are notorious for having a backlog of 30 days, or more.

The one piece of advice that I give advocates is to look at the EOB and tell your patient not to pay the amount listed on the statement without comparing it to the EOB.  It might be necessary to contact the billing agency to confirm that the correct insurance company was billed.  Billing agencies often know that insurance companies have a backlog and payment is slowed.

If the patient is concerned about the potential of a threatening statement, contact the billing or physician’s office to confirm that adverse action will not be taken against the patient.  Most companies are reasonable when approached with positive intent.

If you want to learn more about medical coding for patient advocates, join me at the Patient Advocate Conference.  I’ll be presenting at the Care Coordination Summit’s preconference on April 18 in San Antonio. (For more information, go to carecoordinationsummit.com)

Connie Zeller has been the Director of Education for DecisionHealth for the past four years.  Prior to joining DecisionHealth she worked for Public Employees Health Plan (PEHP) for more than 17 years.  She is a Certified Professional Coder (CPC) accredited through AAPC (American Academy of Professional Coders) and has earned her CCS-P (Certified Coding Specialist – Physician based) with AHIMA (American Health Information Management Association).  Even though her parents and grandparents have passed away, Connie is still the “go to” person in her family to help interpret medical bills.