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

5 on Your Side finds that the definition of "surgery" depends on the code used for the insurance claim.

Posted 9:00 p.m. May 22, 2008 — Updated 2:22 p.m. May 23, 2008

GODWIN, N.C. — 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.

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