5 On Your Side

The definition of 'surgery' depends on who is coding it

Posted May 22, 2008
Updated May 23, 2008

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— When medical procedures are coded for insurance claims, that coding can make a big difference in how much the patient has to pay.

Randy and Tammy Stone, of Godwin, learned about  surgery coding after taking their son, Gerald, to Brown Orthopedic Surgery and Sports Medicine Center in Dunn, where he was diagnosed with a broken foot.

The Stones said doctors told Gerald to wear a special boot he already had. There wasn’t a problem until the Stones received an "explanation of benefits" statement from Guardian, their insurance company. The statement showed a $318 charge for the office visit, a $132 charge for X-rays and a $592 charge for surgery.

The Stones were confused because Gerald didn’t have surgery.

“I was concerned about it ‘cause I knew we had a $200 deductible if it was considered surgery,” said Tammy Stone.

A regular office visit would cost the Stones $20.

Tammy Stone said a Brown representative told her not to worry because it's just how they "code" fractures for insurance purposes.

Then the family received a bill for more than $200 from Brown Orthopedic. The Stones were not able to solve the problem with Guardian or Brown.

“What we've been told since January is there is nothing that we can do … that we have no option but to pay it. And it's … just not fair,” Tammy Stone said.

So the Stones contacted 5 on Your Side.

Brown Orthopedic CFO Jacob Rodman said the fracture code, which also covers any “manipulation,” is in the surgery section of the insurance code book.

However according to notes from the doctor who treated Gerald’s foot, the fracture was "non-operative and non-manipulative."

Still, Rodman claims insurance companies require the additional charge whenever there is a fracture, no matter what is done. He says it also covers any further treatment for 90 days.

Guardian spokesman Jerry Picone told WRAL his company does not require a specific charge for anything.

"You list what you did. If somebody didn't treat a fracture … if somebody just looked at it, then that's an office visit and that's what should be coded and billed accordingly,” Picone said.

Randy Stone said the charge was “ridiculous,” considering nothing was done to his son’s foot.

Guardian agreed to look into the Stone's billing dispute, but on Tuesday decided everything was coded properly. Despite that, Guardian said it will consider waiving the Stones' $200 deductible because the company did not like Brown blaming the codes on insurance companies.

The Stones plan to file a complaint with state Department of Insurance.

36 Comments

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  • raleighheels May 27, 2008

    You want to know why insurance is so high...read this article that can be found in a MA newspaper article.
    Insurers don't like to 'share'

    Dr. Susanne King
    Article Last Updated: 05/23/2008 11:49:38 AM EDT

    http://www.berkshireeagle.com/search/ci_9358676?IADID=Search-www.berkshireeagle.com-www.berkshireeagle.com

    Nice article about the nice salary's of the CEOs of insurance companies..and how their costs are pushed to US, the insured!

  • raleighheels May 27, 2008

    I enjoy 5 on your side...except when things get spun in the wrong direction or not clearly explained. This one was not clearly explained. Sad. Because it is hard for everyone to understand. They did state at the end...EVERYTHING WAS CODED CORRECTLY. Maggie Mae...you have explained it well. Thanks!

  • wilfhh29 May 23, 2008

    I took my 5 year old to his pediatrician this past winter and found out that it is surgery when a doctor cleans out someone's ear. My mom got charged for surgery for a cortizone shot in her wrist, too. The definition of surgery has changed due to the insurance companies.

  • FaceDown-AKA_Maggie May 23, 2008

    Pat. . .you really have no idea what you are talking about. To bill for treating a patient there are specific codes that must be used per injury/treatment, Set by the AMA. It is a huge hassle. These codes do not necessarly encompass the treatment given. . .but there are strict rules about how things have to be filed.
    Have you every seen a coding book? I am a pre-coder. . .it is a nightmare. My codes don't go to insurance; but I can tell you that the codes do not always accuratly describe the procedures. But we have to follow the rules. If you have a problem with the codes the AMA has set out, take it up with them. Don't make judgement calls on something you don't have any idea about.

  • FaceDown-AKA_Maggie May 23, 2008

    "I contacted a professional coder who looked up the code in a coding book and yes there is a code for closed treatment of fracture of (add any bone in the foot) without manipulation. I think you argument is whether you think the service is worth the amount charged."

    Yes, there is. . .but it is STILL a surgery code. The fracture codes vary depending on if it was open vs. closed, and with manipulation vs. w/o manipulation. I was actually going to give a few examles before but decided it would be confusing. All claims are paid according to what is "usual and customary".

  • Kim209 May 23, 2008

    Good going Jacob.....Nice marketing plan!!!! LOL

  • TheBullCity May 23, 2008

    The doctors office and insurance company don't have a leg to stand on. Blaming the coding is the same as saying we refuse to correct this. Maybe the patients should blame the coding when they inform the doctor that they won't be paying.

  • kelleyv May 23, 2008

    I contacted a professional coder who looked up the code in a coding book and yes there is a code for closed treatment of fracture of (add any bone in the foot) without manipulation. I think you argument is whether you think the service is worth the amount charged.

  • FaceDown-AKA_Maggie May 23, 2008

    "Codes put on the forms seem at times to be completely arbitrary. My latest three trips to doc for the same ailment, got same care, three different codes. Two were covered at 80% and one at 50%. Nonsense. You only find out about this when your receive you EOB form. By that time, it's cast in concrete.
    "
    This is easy to explain. . .
    There are many levels of office visits. New patient, old paitent with new problem, recheck of same problem, recheck. . .also codes are based on content and length. . .there are alos codes for referrals, and their respesctive levels of treatment.
    This is all necessary to document treatment.

  • ohmygosh May 23, 2008

    Codes put on the forms seem at times to be completely arbitrary.
    My latest three trips to doc for the same ailment, got same care, three different codes. Two were covered at 80% and one at 50%.
    Nonsense. You only find out about this when your receive you EOB form. By that time, it's cast in concrete.

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