The Minefield of Coding System Traps

Nancy Muller Health Pro
  • In May, The Wall Street Journal ran a feature story1 explaining how patients may be billed for free exams. The article intricately described how this occurs through the doctor's practice administrators who either use the wrong code or fail to understand the insurer's procedures. It caught my attention immediately because I myself have been a victim of such a situation. It's happened to me more than once, specifically with respect to my annual mammogram for breast cancer screening. Only after repeated phone calls, weeks of haggling for corrections in coding, and only after a personal letter to the insurance company's president was the promised coverage enacted. 

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    This happened because at NAFC, in an effort to contain spiraling health care benefit expenses, we have in recent years switched to a high-deductible coverage plan that includes a health savings account to which employees contribute pretax dollars for paying those expenses applied against the deductible. In exchange for their exposure to such expenses, employees enjoy 100% coverage of preventive care, including such procedures as an annual PAP smear and exam for cervical cancer screening, mammograms, PSA tests for prostate cancer screening, and even some immunizations. 


    NAFC is not the exception. In fact, human resources consultant Watson Wyatt Worldwide is quoted in the WSJ article as stating 72% of large companies in 2009 are providing complete coverage of preventive care, up from 55% only a year earlier.

    But the real problem is not miscoding. What is subtly operative is how healthcare financing systems influence the behavior of physicians and their administrators. Under traditional indemnity plans such as PPOs so widely prevalent in years past, doctors typically had to code procedures as purposely diagnostic in nature in order to get paid, as preventive services were not covered. Medicare still functions this way. So under that payment system, if a patient undergoing a routine mammogram were asymptomatic, the doctor would still code the procedure as anything other than "baseline," or first, but instead as diagnostic. However, under a high-deductible, preventive health plan, the insurer's coding only equates "baseline" with "preventive" whether it is the first or the 20th mammogram. The dilemma in this latter scenario for the doctor is that she must lie and term the latest mammogram "baseline" when it is it is actually going to be compared to an earlier mammogram, forcing her to use different medical jargon than she normally would. At a minimum, she must think about the coding system in a different way than in the past and know whether her patient is in one plan or the other.  And unless the patient insured by a high deductible plan digs in and confronts the insurer with the trap that has been laid to avoid paying the doctor, the patient receives a bill for the "free" exam. Should the patient refuse to pay, the medical practice will ding the patient's credit rating.


    We've got to stop the game playing by replacing the system being manipulated by insurers who are avoiding payment to providers for their services and by doctors seeking first and foremost ways to get paid. Under either scenario, the patient loses.  It's time to get serious about comprehensive health care. Good healthcare must include preventive services, including nursing instruction on how to give breast self-examinations in combination with mammograms in the case of breast cancer screening. Patient education must be valued alongside procedures. And we must not have a system that encourages gimmicks and games with coding.


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    Similarly, in the case of overactive bladder, the system should cover a nurse specialist's or physical therapist's instruction on bladder retraining and performing pelvic muscle exercises in combination with coverage of medications, nerve stimulation, and the option of a neuromodulation implant. Get to know all of your options to which you deserve access in the case of OAB.


    Until the healthcare financing system is overhauled, however, we all must remain alert to coding minefields and fight for our rights. 


    Nancy Muller


    1    "Why Patients May Be Billed For Free Exams," The Wall Street Journal, May 21, 2009

Published On: July 15, 2009