My daughter fractured her fibula and needed a cast and a boot. The insurance company applied our $250 deductible for surgical procedures. I asked why the claim was defined as surgery when no surgery occurred, and the claims representative said claims were paid based on the billing code, and that the doctor had submitted the claim using a surgical code, which was appropriate in this situation. She refused to define "surgery." Is it a standard for insurance companies to treat cast fractures as "surgery"? When I asked what billing code was used, the rep said she couldn't tell me and I should contact the doctor's office. The bill the doctor sent me had a fracture listed, but nowhere did it state a surgery. Can I appeal this? Where can consumers find information on what the standards are for defining types of claims?

Amy

Your situation highlights the need for precise communication between medical providers and insurance companies. Accurate claim payments rely on accurate claim information from doctors and other providers. Over the years, minutely specific sets of codes have been developed by various organizations for use by the medical and insurance community. The doctor's office submits a claim to the insurance company using certain codes, and the insurance company pays for the services based on the codes. If imprecise or incorrect information is given to the insurance company, it must be rectified by the doctor's office.
Medical providers and insurance companies use several types of codes, including the following:

• DRG: Diagnostic Related Group. Providers use these codes to describe the diagnosis of the patient or the medical problem that the doctor treated.
  
• CPT: Common Procedural Terminology. This is the code that describes the treatment or medical procedure used by the provider.
  
• ICD: International Classification of Diseases (Clinical Modification). This is another code used to describe the nature of the medical problem.
  

Information on the development and use of codes is readily available in most book stores or in the library. Online information is more difficult to locate, but can be found by searching on any of the acronyms listed above. Begin by browsing to the website of the American Medical Association or the Centers for Disease Control.
Your question raises two issues: the reliance on procedural and diagnostic codes and confidentiality of patient records. In this case, the insurance company is giving the correct information. The payment of the claim is based on the procedural code that the doctor gave the insurance company on the claim form. The claim was paid in accordance with the code designated by the physician. The claim representative may not change codes in order to change the way the insurance company pays a claim. To do so would be to commit fraud.

A claim representative may not give out sensitive patient information because of the need to maintain strict confidentiality. Claim information is confidential and cannot be shared with anyone, even if the person requesting the information professes to be the subject of the information or that person's parent or guardian. Again, there are legal ramifications to sharing confidential information. The standard practice is to refer the person to his or her physician for further information.

So in this case, it is not the insurance company treating a fracture as a surgery. The insurance company is merely acting on information supplied by the physician. The proper place to address this issue is with the physician. While a description of the procedure might not include the word "surgery," the code used by the physician on the claim form might indicate surgery. Either the doctor's office used the wrong code for the procedure, or the procedure itself falls into the surgical category.

You may be able to resolve this to your satisfaction. First, determine how the claim would have been handled if it were classified as something other than a "surgery." In other words, it may be that your out-of-pocket expenditure may be even higher if a different procedure was reported. Second, if you believe that this was a mistake that cost you extra money, speak with your physician and describe the situation. Inquire about the precise procedural code that he or she used, and ask if a different code might be more accurate and not misrepresent the facts.