CPT codes are the billing codes that doctors use to keep track of the services provided to us patients, and to tell our payers (insurance, Medicare, others) what services they provided so they can get paid (reimbursed) for them.
Each year, before the end of the year, the AMA changes some of its CPT codes. Old codes that are no longer being used or are being replaced, are deleted. New codes are added, representing new services or changed services, so doctors can eventually be paid for performing those services or procedures.
For example, here are some of the CPT codes updated in late 2010, for 2011:
New codes added:
- 11045 - Debridement Subcutaneous Tissue, each additional 20 sq cm
- 11046 - Debridement Muscle/Fascia, each additional 20 sq cm
- 11047 - Debridement Bone, each additional 20 sq cm
- 11040 & 11041 Debridement; skin; partial & full thickness
It seems the attempt here was to be sure doctors will be paid for the amount of skin or other tissue they debride instead of just the fact that they performed the service. (Debridement is the clearing away of dead or infected tissue.)
Why is this change in CPT codes important to patients if CPT codes are used only for transactions between doctors and insurers?
When the provider's billing staff uses the wrong CPT codes in the paperwork they send to your payer, then the doctor doesn't get paid. Each year, as the codes change, more mistakes will (naturally) be made. When mistakes are made, the doctor doesn't get paid.
What the doctor's billing staff should do is correct the code and resubmit the bill. But if they lag behind, or if they never correct the code, you may be billed for the service, even though it's their fault.
Further, you may not get that bill until months or years later. Those late bills will never be reimbursed by insurers and other payers who limit the amount of time that can pass for an invoice to be corrected.
When you visited that doctor, you signed paperwork saying you would be responsible for any payments not covered by your payer. That means the doctor's office will expect you to make up the difference.
Smart patients review their medical bills as those bills arrive, making sure that reimbursements are taking place as they should so there will be no billing surprises later.
Here is the information you need to be sure you won't get billed because of CPT coding mistakes:
• How to Read Your Medical Bills
• How to Read Your Insurer's Estimate of Benefits
• A Patients Guide to Medical Codes
Note: These billing mistakes aren't the same as balance billing or upcoding, both of which are illegal but take place every day.
• Learn about balance billing
• Learn about upcoding
Be sure you aren't being taken for a ride by those who want you to pay for services you should not be responsible for.
