Re: Breast cancer mammograms and insurance cost an... - Page 4

HerRoyaLioness · ‎03-13-2010

@Carmie- coding is extremely complicated, as are differing insurance "rules". To become certified is very difficult and requires continuous continuing education as the rules change constantly. The terminology is unique.

Anyone who is not a coder cannot begin to understand - I have a hard time explaining what I did for a living for 20 years - even highly educated people don't get all what is involved. New coders straight out of school have a hard time. People who think they know coding are the most dangerous. If I had a penny for every time a patient told me their insurance said we coded it wrong, I would be rich. I would say 90 - 95% of the time it is coded correctly. We had at least 2 coders review it. At least that's the standard we were held to and we were tested on our accuracy on a regular basis.

The nurses always thought they could code things and they were so wrong so often it wasn't funny. It's not something you can't begin to teach someone overnight. There are so many that don't pass the certification test, that they give you a second chance free!

We cannot base our codes on what might be beneficial for the patient - IT IS FRAUD. Or, on how someone who is not a coder thinks it should be or tries to interpret a coding guideline. Or tries to get a provider to change their dictation. Again, this is considered fraud by the government.

There are about 10,000 CPT codes and 76,000 ICD10 codes. There are tons of things to take into consideration before coming up with the correct codes. It gets crazy. No one realizes how hard we fight to get a claim paid for the patient - we are their advocates. Insurances are paying less and less on their claims as well as not covering services they have in the past. I feel sorry for some of them because they are paying outrageous amounts for their insurance premium. Plus, I have experienced this first hand.

I try not to get involved in these posts, but there is so much wrong information and no easy answers, so I got hooked into this one. I was also a Coding Auditor for a while and had to put up with irate providers who didn't understand why they had to or couldn't do certain things. I told them I was keeping them out of jail!

Carmie · ‎10-25-2010

@HerRoyaLioness I agree with you 100%. Insurance companies cannot tell anyone that their claim is coded incorrectly either.

We always got calls from people wanting to know the Diagnosis or procedure shown on their claim and had to refer them back to their provider.

i am not a coding expert and don't claim to be one. I always referred my coding questions to someone who was and I sure appreciated their help,

I do know that the doctor provides the diagnostic code, not the coder. If a personal history of a malignant cancer is listed on the claim, it is not considered a preventative screening even if the patient has a mammogram once a year as part of her preventative services, If two codes are listed and one is a screening and the other a diagnostic code, the claim will process under the diagnostic benefits.

for a patient, it really doesn't matter, unless there is a copay for diagnostic services. Then they get upset.( I don't blame them)

i would not want that job, I"d rather deal with irate people in customer service, because IMO it's easier.

Tinkrbl44 · ‎08-23-2010

@Carmie wrote:
@HerRoyaLioness wrote:
@Carmie wrote:
Once you have been diagnosed with cancer, all future mammograms will not be coded as preventative.

i don't agree with this, but this is how coders MUST code.

You are not alone in being upset with this. Many women have a very high copay with diagnostic mammograms while a preventative one is paid in full.

there is no way to get this changed, so sorry.

CARMIE, where did you get this information? I am over 4 years out and back to a yearly screening for cancer mammo. I am no longer under treatment for my breast cancer and have had over 3 years of normal, every 6 mos results now. This is the protocol my dr uses.

A mammo should never be coded as part of a preventive visit (annual physical). It is separate testing. We are talking about two different diagnosis codes, in addition to the CPT code.
I worked for a health insurance company for almost 25 years in CS. I received MANY appeals from women who received a mammogram that they thought was for a preventative screening. The provider of the service coded it with a diagnostic code and the claim was processed according to the diagnostic benefits.

i called the provider and asked them to recode the claim as preventative and was told that once something was found during a mammogram, future claims could not be coded as a preventative service.

Well, I didn't like this and didn't agree, so I sent the inquiry to our provider services department and was told the same thing. So, I sent an inquiry to our legal dept and they verified that this was true. They sent me a copy of the coding procedure used by Medicare and all insurance companies.

i felt do bad having to write to these poor women and tell them that they would forever have a copay and not have this service paid at 100%.

if they called me on the phone and most did after they received my letter. I told them that they could try to go to a different provider for their mammograms and ask for a preventative screening.

when they did, some ladies called to tell me that it was coded as a preventative screening because the provider did not know their history.

i don't agree with this procedure at all, but I know 100% that claims are supposed to be coded this way after cancer or some other medical problem is found on a mammogram.

Mammograms and GYN exams are coded as preventative screening services, but you are correct in that they are billed separately from a routine preventative annual exam even if done at the same time by the same doctor.

@Carmie

I have to ask ..... what was the ballpark range of the co-pay? Ten dollars? Fifty dollars?

Carmie · ‎10-25-2010

@Tinkrbl44 All contracts were different. Some people had a $250 to $500 deductible with 80% coverage on diagnostic services which was quite common. That was probably average.

The coinsurance was 20%. Mammograms cost between $100 and $200, so many woman were responsible for the total bill that was applied to their deductible. If their deductible was already met their coinsurance was around $10 to $20.

i am sure those deductibles and coinsurances are much higher now.