My Name is Sarah

MY NAME IS SARAH. I am a quilt designer and the sewcial director of Sarah's Sewcial Lounge. I also have a business called Down Right Charming. I sell my quilts mostly on etsy and I make pillowcases to donate to patients in the hospital in memory of my friend Kristen Kirton. I am a young adult living with Down syndrome. I hope you enjoy reading about my life journey.

Thursday, March 4, 2010

A Crash Course in Medical Billing

by Joyce...In yesterday's post Sarah told you about her 727.1 bunion. I purposely helped her name that post, to be able to use it as a demonstration today. From the time we started this blog, I have read over and over of medical claims being denied for both simple and complex procedures for people with Ds. I thought it might be helpful if I shared some of what my husband and I have learned from our experience owning a medical billing company.

If you are not familiar with the details of billing, it is a nationally standardized process regardless of the payer. All claims, except when in the hospital, must be submitted on a HCFA 1500 form.

The above photo is an example of one. They are printed in red ink for scanning purposes. We are an electronic filer so we are not actually sending this paper form to the insurance carrier, rather the data is submitted electronically, but it must be in the above format so if the end user wants to print it out, the appropriate boxes are aligned. Much of the data is personal info such as name, address, birthdate, insurance number etc...

...until you get to box number 21. That is where the diagnosis is identified. This diagnosis should only be for the treatment for the date of service. This is where the PROBLEM usually starts.
This is the master ICD-9 book. There are thousands of diagnoses to pick from and the key to successful claim payment is to choose the correct one(s) for the treatment of the day. For some reason many medical offices including physical therapists, speech therapists etc. want to put 758.0 as the first DX(diagnosis) code.

As you can see 758.0 is the code for Down's syndrome (yes they still use the "s"). That is almost always NOT CORRECT and is a flag to many insurance carriers to DENY the claim.
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Using Sarah as an example, her diagnosis on a visit could be...

493.2 Chronic Obstructive Asthma. Yes it may seem to be more common in kids with Ds, but millions in the general population also have COA.

same goes with 480 Viral Pneumonia

same goes for 518.81 Acute respiratory failure

even 519.00 tracheostomy complication

and the big one 745.4 ventricular septal defect. All of these diagnoses could be denied if it is accompanied with 758.0
Think like this...the insurance carriers have massive computerized systems in place to DENY your claims. It is like a flow chart, if this dignosis comes in with this diagnosis DENY the claim. Almost always the first denial is simply made by a computer. No human has reviewed the claim. Same with the first refile.
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So how do you avoid this potential problem? Stop at the desk on your way out of the medical office and just say, "I want to make sure when this visit is billed that it not include 758.0. This is especially true when billing for private speech. Most carriers have very limited coverage, if any, for speech delays related to a "chromosomal anomalies" or "genetic disorders". Once 758.0 gets into the insurance carriers system, denies will become the norm.
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Look at it like this, with speech therapy you are not treating the Down syndrome, you are treating a language delay, so why would you use 758.0. With physical therapy, you are not treating the Down syndrome, you are treating a gait abnormality. With a bunion, you are not treating the Down syndrome, you are treating the bunion.
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I hope this helps. If you have a specific question, send me an email and I will give you my best lay advice.

19 comments:

Leah said...

Wow Joyce, this is VERY helpful information! Just today I was talking to someone about difficulty getting some services covered. I hope you don't mind, but I posted a link to your blog post on my FB page. There are an awful lot of parents in the DS community who can use this! THANKS FOR POSTING IT!

Lisa said...

Thanks to Leah and to Joyce! This is useful to schools who bill as well. You don't really think about the dx that is listed first. I do know that as an adult, the company I was looking at for life insurance didn't want to insure me because COA was a primary dx for me.

Definitely food for thought!

Kristin said...

Thanks - I had heard to never let them put Ds as the diagnosis, but didn't know the details. Much clearer now!!

Beverly said...

thanks. Im sure this will come in handy.

Becca said...

Oh, WOW. That was such an eye opener! Thanks for posting that and providing that lesson! I had no idea that was how it worked. Very, very helpful...

Bethany said...

Joyce, did you write this for me? LOL. Thank you!!!!

stephanie said...

Joyce this is info is as valuable as gold. thank you. Do you mind if I print it out because I will never remember all of it.

The VW's said...

WOW, great info to know! Thanks for sharing this with us! This will be helpful to so many! Great job Joyce and Sarah! HUGS!!!

Scarehaircare said...

I am going to bring this up in my Clinical Processes class next week. I am surprised that Ds would get top billing over a specific speech disorder or language delay.

Rochelle said...

Great post, Joyce. Thanks for all the great knowledge you share.

RK said...

This is my kinda post!!! I worked for years in coding, billing, documentation, auditing, and the medical practice side of things. I have often said that it is the biggest blessing that THAT was my background and the business I owned when I had Braska. Now I spend alot of time working with people who get denials "not a covered benefit" when it clearly should have been fine if coded properly. The dx is always to blame, just as you've explained, and it's an ongoing battle.

Our insurance will deny anything with the 758.0 code on it in primary, and often if it's anywhere. We talk to the offices and providers about this every time, but it still turns into a hassle of calling when the EOB or bills are received, explaining again the problem, them still not doing it correctly, and the cycle continues as I go up the chain to another supervisor each call in.

Frustrating, definitely. Thanks for sharing this info, Joyce. It will be helpful to many, I'm sure.

Bethany said...

I'm back. So, if my insurance is saying will cover 20 sessions per year for a congenital anomaly, then they must be doing it right, yes? Even if they are billing it as DS? So weird, I guess it depends on the verbiage of the plan.

starrlife said...

Hmmmm.... very interesting and helpful! Thanks.

Anne and Whitney: Up, Down and All Around said...

thank you so much for this post, joyce!!!!!!!!

Kim said...

Wow, that is amazing information to have. Thank you!

Amy said...

Wow, I did not know this at all... REALLY good to know!! Thanks!

To Love Endlessly said...

that is such a great post! I just got through fighting our insurance company for speech services for Marissa. Their reasoning being that children w/ DS aren't authorized speech services until 18 mo. Can I link to this post on my blog?

Anne and Whitney: Up, Down and All Around said...

I saved this post when I read it "just in case" we have this problem with Whitney... I am going to share it with some other moms, particularly one mom who just posted on facebook that her new insurance company as of 1/1/13 is denying ot, pt and st all because of the diagnosis of Ds. hopefully it will help her little girl :) thank you so much, again, for taking the time to share this invaluable knowledge with us!!!!!!

Brent said...

I would like to thank you for the efforts you have made in writing this article. This is great.

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