June 8, 2022 | Insurance Claims

The medical coding system is quite complex. It is therefore not surprising that many mistakes are made during the claims process. Unfortunately, even a small error in the claims processes can result in the denial or delay of payment of medical claims. A delay or denial of a medical claim can have serious consequences. It is therefore important to learn about insurance diagnosis codes and the most common errors that occur during the claims process.

What are Insurance Diagnosis Codes?

Insurance diagnosis codes or insurance codes for short are codes that are used by insurance providers to make decisions about requests and claims. Insurance providers use these codes to determine how much they should pay your healthcare provider when you make a claim. These codes are often included in your medical bill and Explanation of Benefits.

The Explanation of Benefits (EOB) is a document that insurance providers send to policyholders after they have had a healthcare service for which they have made a claim to the insurance company. The EOB outlines your medical billing history. You can use it to check and see if your diagnosis and the medical procedure have been listed and coded correctly.

Insurance codes were developed to provide a reliable and consistent way for health insurance providers to process claims. Insurance companies currently use three different types of coding systems. These are:

• Current procedural terminology (CPT) – These codes are used to provide a description of the services provided. Healthcare providers cannot be paid for the services they have offered unless a CPT code has been included on the claim form.
• Healthcare Common Procedure Coding System (HCPCS) – This coding system is used by Medicare. These codes are similar to CPT codes. However, Medicare also maintains HCPCS Level II codes that include products, services and supplies that are not covered under CPT codes.
• International Classification of Disease (ICD – 10) – These codes, developed by the World Health Organization, are used to identify health conditions or medical diagnoses.

Common Issues Surrounding the Use of Insurance Codes

While insurance codes were introduced to standardize the processing of claims, they present various challenges. These coding systems are complex. It isn’t uncommon for people to make mistakes in coding that often result in denial or delay of claims. Below we discuss some of the most common errors encountered when using these codes.

1. Including the diagnosis code but not the procedure code

Insurance companies require healthcare providers to include both the diagnosis and procedure codes when making the claim. Forgetting to include any of the codes can result in a huge loss in reimbursement. It may even result in the insurance claim being denied or delayed.

It is important to include as much detail as possible when it comes to insurance claim codes. Being detailed maximizes reimbursements.

2. Using outdated codes

Coding systems don’t remain the same forever. They are regularly updated to ensure that they remain relevant as well as to improve efficiency. However, some people continue to use outdated codes in filing claims. This often results in the denial of a claim. The consequences of this can be costly for healthcare providers.

3. Confusing letters and numbers in filling out claims

Another common error in filing claims is confusing letters and numbers when filing a claim. For example, instead of using a number zero, the person filing the claim uses the letter O or the person uses the wrong letters or numbers when preparing the claim form. This can result in the claim being denied.

It is important to pay close attention to the details on your claim. It will save time in going back and forth while trying to figure out what went wrong.

4. Leaving out specifics

It is important to be as specific as possible when filing a claim. This means providing details on what part of the body was affected, the disease processes and the specific diagnosis given.

Unlike earlier versions, ICD – 10 allows claims to be more specific and accurate. This ensures maximum reimbursement. However, filing claims under the new system is something that many people are yet to get used to.

Help with Insurance Diagnosis Codes Errors

Filling out and submitting a medical claim involves various steps. There are various humans involved along the entire process. The chances of making mistakes along the way are therefore very high. It is therefore not uncommon for a claim to be denied or delayed as a result of insurance code error.

If your claim has been denied, you should seek the assistance of an experienced attorney. We will investigate your case to determine why the claim was denied. We will fight to recover maximum compensation and ensure that you receive the medical care you need. Contact us now to consult with an experienced attorney for free.

What are Insurance Diagnosis Codes?