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How does the ins co know the incorrect diag code was used?
Are you concerned about the $100? That sounds like your standard policy co-pay for an ER visit, and has nothing to do with the billing issue.
Also remember that there is a contract in place between BCBS and the hospital IF IT WAS IN NETWORK. If so, the billing dispute should not be your problem. Is it in network?
If not in network, you are responsible for charges by the hospital that are not reimbursed by insurance. Sure you can ignore the bill ("not paying another dime"), but you're either going to negotiate them down or you're going to pay them or a collection agency. Hospitals don't play around with patient bills these days, and don't cut much slack to insured patients.
How does the ins co know the incorrect diag code was used?
Are you concerned about the $100? That sounds like your standard policy co-pay for an ER visit, and has nothing to do with the billing issue.
Also remember that there is a contract in place between BCBS and the hospital IF IT WAS IN NETWORK. If so, the billing dispute should not be your problem. Is it in network?
If not in network, you are responsible for charges by the hospital that are not reimbursed by insurance. Sure you can ignore the bill ("not paying another dime"), but you're either going to negotiate them down or you're going to pay them or a collection agency. Hospitals don't play around with patient bills these days, and don't cut much slack to insured patients.
Thanks for your thoughts, however your assumptions are not correct in this case.
It is in network but here are the specifics: I have $0 copy for an accidental injury-- this was confirmed but BCBS. I pay a coinsurance percentage if it's a medical emergency. This the the crux of the matter. I had an accidental fall which means I should pay nothing. The diagnosis codes are related to the pain from the fall. The occurrence code states general accident. (This is what the supervisor at the hospital told me). Currently BCBS is paying as if it's a medical emergency, not an accident, which leaves me owing a lot more than what I owe under the terms of the insurance. I am trying to get BCBS review to pay this claim fairly, under the terms of my insurance.
I even asked the billing supervisor if there were another diagnosis code they could have used but she told me there is no diagnosis code for accidental injury. I have no way of knowing if is is accurate or not.
I agree with you about not being cut slack so that's why I am talking to both sides sooner rather than later. If you are uninsured hospitals waive the cost but we all pay/overpay when we have insurance, because we are paying for those uninsured folks. That's the reality of healthcare in 2016.
You could have saved some effort if you had been more up front with the facts at the beginning. Nonetheless, there still seems to be some confusion.
- an accidental fall is not medical. An injury to a specific body part is medical and coded via ICD9 (at least in most places).
- It is also the case that ICD9 codes do not include "accidental" injury, just injury, so the supervisor is correct, but it raises the issue of what your insurer counts as "accidental injury" and how they know an injury is accidental?
- you might ask what kind of occurrence codes are used by BCBS, and compare to what the hospital reported for you. Coding disconnects are not out of the question.
You are no doubt dealing with ICD9 coding issues. ICD9 is a code system now used for both insurance billing and for research purposes, since the CDC collects statistics through the codes. the system includes both diagnosis codes and procedure codes, usually coded as primary and secondary. On top of that, there's another group of codes, CPT, used for physician (and a few other allied health providers like PT) for billing for their services. ER visits are often tricky because ER staff may be contract employees, so out of network, adding another layer of complexity.
Coding and billing is an extremely complex area, often done wrong by health care providers. In your case, looks like the insurance company erred too.
Yes, appealing may be the best solution at this point.
Every claim, whether outpatient or in a hospital or ER, generates two types of codes, not just ICD codes (and it is actually now ICD 10, not ICD 9).
The first code is a CPT (current procedural terminology). They cover
Evaluation and management (work done by the physician)
Anesthesiology
Surgery
Radiology
Pathology and laboratory
Medicine
The CPT codes for evaluation and management are extremely complicated and are designed to quantify the complexity of the service provided. Here is what Medicare requires for an ER physician to use CPT code 99285:
An ER visit will generate CPT codes for the ER doctor, the hospital for facility use, any laboratory tests done, any x-rays done (and for the radiologist who interprets them) ...
ICD (International Classification of Diseases) codes describe the circumstances leading to the visit, and ICD 10 includes a gazillion of them, some of them hilarious, such as
V91.07XA – Burn due to water-skis on fire, initial encounter
After you are treated for such a burn and have a follow-up visit, the code becomes
V91.07XD - Burn due to water-skis on fire, subsequent encounter
Those codes are for data mining. They allow the incidence of injuries due to water skis on fire to be determined.
Let's suppose the actual injury was to the right foot and was a second degree in severity:
T25.221A - Burn of second degree of right foot, initial encounter
Here are all the burn codes for the ankle and foot:
Suppose the ER doc applies a bandage to your burn:
2W2SX4Z - Dressing of Right Foot using Bandage
Does anyone wonder now why coding errors are so common?
Quote:
Originally Posted by sunshinyday
Thanks for your thoughts, however your assumptions are not correct in this case.
It is in network but here are the specifics: I have $0 copy for an accidental injury-- this was confirmed but BCBS. I pay a coinsurance percentage if it's a medical emergency. This the the crux of the matter. I had an accidental fall which means I should pay nothing. The diagnosis codes are related to the pain from the fall. The occurrence code states general accident. (This is what the supervisor at the hospital told me). Currently BCBS is paying as if it's a medical emergency, not an accident, which leaves me owing a lot more than what I owe under the terms of the insurance. I am trying to get BCBS review to pay this claim fairly, under the terms of my insurance.
I even asked the billing supervisor if there were another diagnosis code they could have used but she told me there is no diagnosis code for accidental injury. I have no way of knowing if is is accurate or not.
I agree with you about not being cut slack so that's why I am talking to both sides sooner rather than later. If you are uninsured hospitals waive the cost but we all pay/overpay when we have insurance, because we are paying for those uninsured folks. That's the reality of healthcare in 2016.
As you can see above, there really is no code for "accidental injury" per se.
Exactly how did the accident happen? Here are a few ICD 10 codes for falls:
What happened to your body when you fell? Did you get any cuts or bruises? Sprain or strain an ankle? Hit your head?
Suppose you hit your right shoulder and got a bruise:
S40.011A - Contusion of right shoulder, initial encounter
M25.511 - Pain in right shoulder
See how it works? If you will share the details of the fall and what codes were used, I may be able to see what the problem is. Feel free to send a DM if you wish.
I have a situation where the insurance company wants the diagnosis code rebilled but the hospital says they won't rebill, it's on there, it's just not the first code listed.
The following link outlines how a hospital should bill accidents resulting in injury on the UB-04 claim form. While the link is from BCBS-KS, UB-04 claim billing is standardized and should give you some idea of what your carrier is looking for.
Where the link refers to principal/primary diagnosis, it is referring to the ICD-10 diagnosis listed in the first position of UB-04 Form Locator 66. Additional ICD-10 diagnosis listed after that are referred to as secondary diagnosis. It is illegal for the carrier to change the principal diagnosis.
Now I know why healthcare is so out of control expensive. They have armies of people who dream up codes and another army of people who try to figure out what the right code is. Sheeesh.
Now I know why healthcare is so out of control expensive. They have armies of people who dream up codes and another army of people who try to figure out what the right code is. Sheeesh.
You could have saved some effort if you had been more up front with the facts at the beginning. Nonetheless, there still seems to be some confusion.
- an accidental fall is not medical. An injury to a specific body part is medical and coded via ICD9 (at least in most places).
- It is also the case that ICD9 codes do not include "accidental" injury, just injury, so the supervisor is correct, but it raises the issue of what your insurer counts as "accidental injury" and how they know an injury is accidental?
- you might ask what kind of occurrence codes are used by BCBS, and compare to what the hospital reported for you. Coding disconnects are not out of the question.
Didn't mean to be obtuse, just didn't want to bog down with the details.
Thanks this is helpful. I just received a copy of the actual form the hospital submitted, so if/when BCBS refuses to pay correctly, I will be asking more info re the the codes from BCBS, as to what they are expecting specifically.
I even asked the billing supervisor if there were another diagnosis code they could have used but she told me there is no diagnosis code for accidental injury.
When you talk to BCBS, there should be no mystery on how to code for accident. Excellent information, here:
Quote:
Originally Posted by SCGamecock
The following link outlines how a hospital should bill accidents resulting in injury on the UB-04 claim form. While the link is from BCBS-KS, UB-04 claim billing is standardized and should give you some idea of what your carrier is looking for.
Where the link refers to principal/primary diagnosis, it is referring to the ICD-10 diagnosis listed in the first position of UB-04 Form Locator 66. Additional ICD-10 diagnosis listed after that are referred to as secondary diagnosis. It is illegal for the carrier to change the principal diagnosis.
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