Author Topic: Letter from Insurance Company  (Read 4989 times)


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Re: Letter from Insurance Company
« Reply #15 on: August 27, 2014, 05:21:12 PM »
I have a bit of a different take on this.  The practice of medicine and the verbalization of what was wrong came first.  At some point that verbalization began to be written down.  So we then had the practice of medicine plus the writing down of the diagnosis.  All of this existed way long before computers were invented.

The ICD and CPT codes are an attempt to turn into computer language what the doctors have been writing down for centuries.  It is the written diagnosis / procedure that is the legal definition of what is wrong with the patient and how it was addressed - not the ICD and CPT codes.

So - a doctor may be extremely proficient at making diagnoses (plural), and less proficient in selecting the codes that best match his diagnoses (plural).  That is, after all, what ICD10 is supposed to address.  The ICD9 codes are much less specific; the ICD10 codes, of which there are thousands more, are much more specific.

So - if the doctor's written notes support a 362.11, but the doctor wrote down 362.10, is it illegal to change the code?

If an insurance phone person says "we can pay this if you can change it to 362.11", I would like to think they are saying "have the doctor check his notes to see if they will support a 362.11".  To me, that is an approach far removed from simply advising someone to change a code just to get it paid.

As we approach the change-over to ICD-10 (assuming it ever happens), I imagine it is going to be a nightmare of incorrect coding submitted to the carriers.  I would not be surprised if they are training their staff in the art of educating their clients (the doctor's and their staff who submit billing to them) on which codes are more useful, and which codes are less useful - assuming the written documentation supports the more useful codes.
« Last Edit: August 27, 2014, 05:23:37 PM by RichardP »


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Re: Letter from Insurance Company
« Reply #16 on: August 27, 2014, 05:43:38 PM »

I am glad that I am not the only one that has noticed this "new" trend.   Is this legal now?  Isn't it still unethical and illegal to change dx just so insurance company will pay the claim?    I shudder at the thought.....

Yes it is.. IF this is a new trend .. which sorry folks, I'm not buying it because I've worked for a few of the top 5 carriers, then I would think it's up to US to do the due diligent thing.. carriers make the disclaimer that "verification of benefits is not a determination of payment.. blah blah.." well it's up to us also to adhere to our own ethical standards and following the rules. One would ONLY hope that an experienced professional would NOT do something because a carrier told them to do so. I'm just NOT ready to believe a carrier would say this.. people don't understand how they go through the rating process and how that could easily bring their rating down.. I'd really HAVE to see the letter to believe it.. I just don't.   J M H O
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