Posts Tagged insurance claims
The International Classification of Diseases version 10 is called ICD-10. Here is an example: S06.5X9A You can look this up on the CMS web site (ICD-10 Lookup) to find “Traumatic subdural hemorrhage with loss of consciousness of unspecified duration, initial encounter (that’s bleeding around the brain due to a blow to the head which the provider evaluated for the first time).
So, why is this important to you as a health care consumer? Because the bills sent to insurance companies use these codes — if the code is wrong then insurance will reject the claim. By looking up the code you will actually know the technical diagnosis made by your provider — something to add to your DIY medical record especially if it is a critical diagnosis in your situation.
The diagnosis codes are intended to force providers to be very specific about the conditions they treat. The people who connect diagnosis to outcome find the codes very valuable — which in turn helps consumers know how providers perform.
The codes are not always seen by the consumer — they are transmitted on insurance claim forms. In fact, insurance companies will refuse to tell you what diagnosis was used to bill services. But, the codes often find their way into the medical record — as they should.
The ICD-10 code tells the diagnosis. A companion code called Current Procedural Terminology (CPT code) tells what service was provided (like an office visit, or perhaps a brain surgery). ICD codes are in the public domain but the CPT codes are produced by the American Medical Association and are copyrighted.
From a purely economic standpoint the CPT codes serve primarily to fractionate the health care market to maximize profit for providers. It is helpful to know what service is provided but the CPT codes are blighted by meaningless detail. And, they are hard for the consumer to decode because of the proprietary nature of the codes. Many feel the CPT codes are part of the cause of high health care cost in the US. They should be scrapped and replaced with some international standard.