EOB? CPT? ICD-9? Ei Yi Yi!!
Ever wonder what all that paperwork from your insurance carrier or doctor means? What’s an EOB? Who’s every heard of CPT codes or ICD-9?
Well, EOB means Explanation of Benefits and it’s basically a form sent to you from your insurance carrier regarding a bill submitted by your physician for a recent visit. This bill is related to a recent office visit with your doctor and potentially for any extraneous tests or labs you had done in association with your doctor’s visit. It lists the amount(s) charged, any deductions your insurance takes off the charges because of contractual agreements previously made with your physician, and then the final amount you may owe to your provider. This final amount is also calculated according to whether you have a deductible and if it’s been met or not. While this is NOT a bill, this same paperwork is sent to your physician, who typically uses that to then send you a bill for the services rendered.
CPT codes stands for Current Procedural Terminology and it is the standard way in which your physician bills your insurance carrier for services rendered. For instance, if you saw your physician for follow up on your high blood pressure and diabetes, your doctor will submit a bill with a CPT code that bills either or according to the complexity of the medical issues addressed or according to the time the physician spent providing counseling and direct care.
ICD-9 is the International Classification of Diseases and it is the way your doctor codes the various medical problems or concerns you have when you visit him or her seeking medical guidance. For instance, the common cold has it’s own diagnosis code as do high blood pressure, diabetes and all other commonly seen medical problems. These codes are used by your physician to explain to your insurance what issues were addressed or discussed during your visit, and thus help to determine the charges sent to your insurance company.
So, as an example, if you went to your doctor to discuss your cold you’ve had for 10 days and then you mentioned you had a mole that had changed recently and also you had pain with urination, your doctor might submit a bill that comes back as an EOB to you as follows:
Your EOB may show:
99214 (CPT code) for a 25min office visit for: Upper Respiratory Infection (ICD-9 code:460) and Dysuria (ICD-9 code: 788.1) and Benign Nevus (ICD-9 code: 216.5)-$125 charged
81000 (CPT code) for a urine analysis done in the office-$20 charged
Total Billed to Insurance: $145.
Your insurance may deduct a % of the bill depending upon the contract with your provider. So if, for instance, your insurance has agreed to only pay $125 for these services, the total amount due to the provider is only $125. If you have a deductible and haven’t met it for the year, this will be the amount that you may owe. Your provider will then likely be sending you a bill for the final amount of $125 that you owe them.
If you ever have any questions about the codes or charges on an EOB or what was paid or not paid by your insurance, you should feel free to contact either your insurance carrier or the provider for clarification