YOU’VE probably heard about ICD-10 codes in conversations with your medical scheme or insurance broker, but for many of us, ICD-10 codes are a mystery.
They’re an internationally recognised system that translates medical conditions into specific codes. They allow the likes of medical schemes and gap-cover providers to understand the reasons for certain treatments, procedures and hospital admissions - and ensure they pay from the correct pool of funds within your benefits.
Consumers should therefore empower themselves with an understanding of how ICD-10 codes work, and what diagnosis they represent, to ensure that their medical scheme benefits last longer, and to avoid claims being delayed or even rejected.
In our opinion, the combination of your medical scheme and gap cover represents one of the most important types of insurance you have. Yet we find people generally know too little about how to extract the most value from their benefits. We feel that is essential that your medical financial planning forms part of your overall financial management.
Clerical issues can certainly happen any time, and despite the care and diligence they take to create accurate information, it is possible for medical practitioners to associate the wrong codes with certain procedures.
Normally, honest mistakes have no impact on the medical care that you receive, but they can have big implications in your medical financial affairs. For example, a colonoscopy may be mislabelled as a general screening, when it is in fact part of a series of procedures to address a confirmed case of colon cancer.
Same procedure; but very different reason, and a different ICD-10 code applies.
The kind of situation that arises most often, is when the bill is submitted to the medical scheme, and it pays for it, so the member doesn’t think anything more of it.
But a portion of the funds has been taken from the member’s medical savings pool, rather than from the defined benefits that are appropriate to that diagnosis.
Ultimately, this means people are digging into their savings for things that they might not need to, leaving them without those savings funds available later in the year.
For all procedures - and particularly for major ones - it’s vital for consumers to have a good handle on the ICD-10 codes that are applicable. For instance, certain procedures could be processed as a prescribed minimum benefit (PMB), which are the conditions that medical schemes are obliged by law to cover.
However, in order to ensure that it’s processed as a PMB with the correct ICD-10 code, you might have to go to certain hospitals belonging to an approved network (depending on the specific medical scheme plan that you’re on).
Without proper planning, you might accidentally choose the wrong hospital, and end up with the wrong codes being applied, or being left with out-of-pocket expenses.
Just where should customers go to find out exactly what codes should reflect on doctors’ invoices to their medical scheme?
Consumers should draw on the knowledge of their financial adviser or medical scheme, which would usually be able to confirm what is the correct ICD-10 code.
Getting to know ICD-10 codes might not be the most enthralling prospect, but, ultimately, without a thorough understanding of which code should apply to which diagnosis, you could be decreasing your medical scheme benefit.
Tony Singleton is the chief executive of Turnberry, an insurance provider.