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CEO: Coding Matters

November 22, 2023

Scott Thoreson, CCMH CEO

By Scott Thoreson, CCMH Chief Executive Officer

Healthcare is one of the most complicated service industries to determine the ultimate price the consumer (in the case of healthcare, the patient) pays. Hospitals have what’s known as a “chargemaster” or a list of all possible charges that can be billed to a patient. At CCMH, we have just under 10,000 charges. The chargemaster contains a mix of CPT Codes, HCPCS Codes, Revenue Codes, along with a description of each charge and its price. These codes are unique to each service and is sometimes dependent upon the location of the service (Emergency Room, Family Practice Clinic, Inpatient, etc.), and there are new codes created or reassigned often.

At CCMH, we employ coders who review the documentation from our providers and other personnel to determine the appropriate code(s) to use when developing charges. Once coders have completed their portion, our billing department then determines how to get that information to Medicare, Medicaid and a multitude of other various insurance companies. As this process continues, we are also informed as to what financial expectations are expected from the patient in the form of deductibles, co-insurance or co-payments. As a reminder, deductibles are usually a set amount per year, such as maybe $1,000 per person on the health insurance policy, or a higher amount when considering all the members of a family on that particular policy. Co-insurance is usually stated as a percentage of charges or allowed charges from the healthcare provider. Co-payments are usually an amount that is expected to be paid per encounter, such as with a clinic appointment or a trip to the emergency room.

In my career, a common question/complaint that is raised by patients relates to a patient who is coming in for a colonoscopy. Once a patient reaches 50 years of age, it’s common for a physician, nurse practitioner or physician’s assistant to request they be screened for colon cancer. In most cases, the patient has no indication of health issues associated with colon cancer, but the procedure was ordered as a preventative measure. Unfortunately, it is not uncommon for the physician performing this procedure to find and remove a polyp(s) in an otherwise healthy patient. What was considered a “screening” colonoscopy is now considered a “diagnostic” colonoscopy. These procedures have different codes and therefore different charges. They are then treated differently by insurance companies. Since screening colonoscopies are known as preventive care, they are often covered by insurance – usually at 100 percent, or with very little cost to the patient. However, a diagnostic colonoscopy is no longer seen as preventative and insurance companies pass along a larger portion of responsibility to the patient. Polyps cannot be detected without performing a colonoscopy, which means it’s impossible to determine if the procedure is truly a “screening” beforehand. Patients often report contacting their insurance companies after they receive a bill to inquire why the charge was higher than expected, only to be told, “if the hospital codes it differently, insurance will pay.” Procedure codes and charges are based on what is actually performed and changing codes to get insurance companies to pay us more is considered billing fraud and not a viable option.

A number of years ago, Medicare initiated the “Annual Wellness Visit” (AWV) which encouraged Medicare-aged patients to schedule an AWV, which essentially is conducted by nurses and perhaps a short visit by a physician, nurse practitioner or physician assistant. During these appointment types, patients receive information on what they should be doing for their own healthcare and it is essentially an educational visit with no cost to the patient. There is no actual hearing of complaints or a physical examination, as that would then turn the AWV into a “problem-focused visit” and it would not be paid for by Medicare. Another point of patient billing controversy results from patients who come in for this AWV and then share information about new health issues. It is then no longer considered an AWV paid for by Medicare. Again, another reason why “coding matters” and as health care providers, we are required to document, code and bill for what actually happens with patients.

Thank you for the opportunity to share some information about “why coding matters” and some of the common billing related questions and complaints we receive as health care providers. If you have a question you would like addressed in this column, please send it to I wish you good health!

More in this Series:

CEO: Maternity Care Desert (Published October 25, 2023)

CEO: Rural Emergency Hospitals (Published September 20, 2023)

CEO: Primary Care Provider (Published August 23, 2023)

CEO: Supply Shortages (Published June 28, 2023)

CEO: CCMH Named Top 20 Critical Access Hospital (Published June 14, 2023)

CEO: Hospital Week 2023 (Published May 3, 2023)

CEO: Prior Authorizations (Published April 5, 2023)

CEO: Staff Shortage and Open Positions (Published February 8, 2023)

CEO: End of Year 2022 (Published December 14, 2022)

CEO: Purpose of the Foundation (Published November 10, 2022)

CEO: Health Insurance Portability and Accountability Act (Published September 28, 2022)

CEO: CCMH Providers (Published August 24, 2022)

CEO: Financial Assistance (Published July 20, 2022)

CEO: Social Determinants of Health (Published June 29, 2022)

CEO: National Hospital Week (Published May 11, 2022)

CEO: Why Healthcare is Expensive (Published May 4, 2022)

CEO: A Hospital is Still a Business (Published March 16, 2022)

CEO: Different Types of Hospital Ownership (Published February 1, 2022)

CEO: Holiday Message (Published December 20, 2021)