Many insurance companies have aggressively marketed their disability insurance coverage to physicians, dentists and others, specifically targeting “specialists” with attractive “Own Occupation” protection. The insurance companies induced these professionals to purchase disability insurance with liberal definitions of Total Disability, such as “the inability to perform the material and substantial duties of Your Own Occupation, They further explained that if the phsician had a board certified speciality, the Own Occupation is defined by that speciality. The continue representing that if the physician cannot fulfill the duties of the specialty due to an injury or illness,but can work in another area of medicine, the physician can collect full benefits. However, many physicians have found that the promises made to them when they purchased the coverage were not honored when they suffered an injury or sickness and became occupationally disabled in their specialty.
When a disability insurance claim is filed, the insurance carrier will “investigate” both the claimant’s medical condition and limitations, and the duties of his or her occupation just prior to the disability. The purpose is to determine whether the claimant’s limitations prevent him or her from engaging in their actual occupational duties. While a physician may be ABMS Board Certified in a particular specialty, if he or she does not bill the vast majority of time practicing that specific role, they are not considered specialists for whatever area they are certified.
In investigating a physician’s pre-disability Own Occupation, very often an insurance carrier will either significantly focus its evaluation on or exclusively look to CPT codes to define the physician’s pre-disability occupation. The problem is that a significant focus on CPT codes is a fundamentally flawed way to evaluate a physician’s pre-disability occupational duties. In fact, if the insurance company predominately considers CPT codes to define what the physician’s occupational duties were prior to his or her occupation, this will unreasonably and inappropriately classify the physician out of his or her actual specialty.
Take for example a physician who is Board Certified as an interventional cardiologist. She becomes unable to perform interventional cardiology procedures in the catheterization lab due to knee and back injuries, but she can now work as a general cardiologist. She asserts Totally Disability claim under hertheir Own Occupation policy. The insurance carrier reviews the pre-disability CPT codes and alleges the claimant was a cardiologist, who also performed interventional procedures, because it determined most CPT codes were “non-surgical” in nature. Because the insurance company focuses on pre-intervention consults and post-intervention consults, the insurance company takes the position that only one-third of the time was spent doing procedures and two-thirds with office visits.
What Are CPT Codes?
CPT codes are five-digit codes used by physicians to report their procedures. CPT codes were created by the American Medical Association for billing insurance companies and the government, but not for determining physician’s duties.
The Centers for Medicare and Medicaid Services (CMS) use CPT codes to track data on various procedures.
CPT codes were introduced in 1966 and have changed several times over time. Currently, there are more than 10,000 CPT codes in use.
These codes fall into three categories:
- Evaluation and management services
- Diagnostic services
- Procedural services
Evaluation and management services are typically office visits or consultations. These codes show the time spent evaluating a patient and the complexity involved in the case.
Diagnostic services are tests or procedures performed to diagnose a condition, such as; X-rays, MRIs, and biopsies. Procedural services are codes that describe surgeries or other invasive procedures.
There are many categories of CPT codes.
Procedure Codes
Procedure codes are essential for medical billing. They show what procedures took place on a person, like surgery or a test. Insurance companies use this information to decide how much to pay the doctor.
Hospitals and other health facilities also use these codes to see what procedures people are getting.
These codes can be confusing, but they are necessary for medical billing. By understanding them, you can ensure your providers get adequately paid for their services.
Anesthesia Codes
There are different types of anesthesia. General anesthesia is when the person is unconscious and cannot wake up. Regional anesthesia happens when the person is awake, but the pain is in a specific area.
Local anesthesia happens when the person is awake and can respond, but part of their body is numb. Each type of anesthesia has its code that insurance companies use to reimburse people for care.
Anesthesia codes are an essential part of medical coding and billing. They help make sure that patients receive the right level of care.
Appealing a Denial Based on CPT Codes
Suppose an insurance company denies an orthopedic surgeon’s LTD claim based on the CPT codes associated with the orthopedic surgeon’s procedures. In that case, the orthopedic surgeon can appeal the denial.
When appealing a denial, it’s essential to have all of the relevant documentation on hand, including:
- The original denial letter from the insurance company
- A complete list of all CPT codes associated with the procedures you’ve performed
- Documentation from your office or hospital showing that you did commit the policies in question
- Any other documents that may be relevant to your case
- Explain why it is common to have several office visits before and after a procedue and that those visits are inextricably linked to the procedure or surgery.
Once you have all this documentation, you’ll need to write a letter to the insurance company outlining why you believe the denial was improper.
This letter should be clear and concise, and it should include all of the relevant documentation.
Just like practicing medicine on yourself is not a good, idea, appealing an insurance claim denial without the assistance of a knowledgeable lawyer can be a mistake.
Appealing a denial based on CPT codes can be a complex process, but it’s important to remember that you have the right to appeal any denial from an insurance company.
If you have questions about appealing a denial, you should speak with a lawyer specializing in LTD claims.
Increase Your Chance of Success
It can be frustrating to receive a denial from an insurance company, especially if you have followed the proper procedures. In many cases, denials are based on CPT codes.
If you are concerned that your claim may be denied based on CPT codes, there are a few steps that you can take to increase your chances of success.
First, keep copies of all documentation you submit to the insurance company, such as any correspondence from the insurance company.
Second, make sure that you understand the specific CPT codes that were used to describe your service. If you have any questions, don’t hesitate to contact your medical provider.
Finally, appeal any denials promptly. By taking these steps, you can improve your chances of getting your claims approved.
Ready to Make Your Long-Term Disability Claims?
Filing for long-term disability (LTD) is a claim filing process that can be confusing and frustrating. This article addressed how CPT codes affect orthopedic surgeons’ long-term disability claims and appealing claim denials.
If you are planning on filing an LTD claim, it is essential to understand all the steps in the process. Contact us for a complimentary review of your LTD claim.
