Charged for preventive care? Here's what might be happening.
When you use health care, your doctor has to communicate with your insurance carrier so they know exactly what was done and how to cover the service. The language they use is a series of codes—about 8,000 of them, in fact. While you don’t need to understand what they all mean, just knowing that they exist and asking questions can help make sure the coding is right. This is extra important for preventive care that should be covered at 100%.
The purpose of “coding” is to prepare bills accurately and consistently, and to determine how much you and your insurance carrier each have to pay. There are two types of codes you should be aware of.
CPT® (which stands for Current Procedural Terminology) codes are five-digit numbers used to describe the service. The codes are managed by the American Medical Association, so they’re the same across carriers and doctors. Here are a few you’re likely to see for preventive care:
- 99385: preventive care for new patients ages 18 through 39
- 99386: preventive care for new patients ages 40 through 64
- 99395: preventive care for established patients ages 18 through 39
- 99396: preventive care for established patients ages 40 through 64
ICD (which stands for International Statistical Classification of Diseases) codes are strings of numbers and letters that describe why the service was provided. With so many possible reasons, choosing an ICD code requires an experienced judgment call by your doctor. For instance, a colonoscopy could be coded as “preventive” if it’s part of a routine screening. Or, it could be coded as “diagnostic” if it’s done to figure out why you’ve been experiencing pain. Here are a couple of common ICD codes used for preventive care:
- Z00.00: general adult health checkup
- Z01.419: routine gynecological exam
- Z12.11: colonoscopy screening
- Z12.39: breast exam
With so many CPT and ICD codes and combinations, it’s easy to imagine why coding is so complicated, and why mistakes could be made. Things also get tricky when preventive procedures lead to diagnostic efforts in the same visit. For example, what if your doctor finds a polyp during your colonoscopy, and removes it to be tested? The diagnostic work would be coded differently than the preventive work, and a charge might show up on your bill for the diagnostic part.
That’s why it’s important to ask your doctor’s office staff—while you’re there—if your visit will be coded as “preventive.” Think about it … how a service is coded determines how much you pay for it. And, in many cases, the codes don’t even appear on the bill or Explanation of Benefits you receive afterward.
So if you’re reviewing the bill later, what should you do if you’re surprised to see a charge for preventive care that should be covered at 100% (i.e., free)? Call your doctor’s office and ask if each service (CPT code) was recorded as preventive (ICD code). If something was coded differently, ask for a reason. You may be able to fix a costly mistake if you catch something that should have been coded as “preventive.”
Benefits and services available may vary from plan to plan—please refer to your plan’s Summary Plan Description for exact coverage details. This article is not intended to provide medical advice. Aon does not recommend or endorse a particular course of medical treatment. If you have any questions concerning your medical condition or any drugs, treatment plans, or new symptoms, consult your health care provider.
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