Why Are Medical Codes Important In Personal Injury Cases?

by | Published on May 11, 2022 | Medical Record Review

Medical record review for personal injury cases also involve reviewing the relevant medical codes related to the injury. What are personal injury medical codes found in the medical bills? How are they significant in a personal injury case?

The ICD (International Classification of Disease) codes are used to classify injuries, diseases and causes of death. These codes are required on every medical claim submitted to health insurers and help insurers understand why the treatment was medically necessary. Among the approximately 70,000 codes, there are many which relate to personal injuries. Personal injury ICD codes are very important because the payers utilize these to assess the value of the claims. So, it follows that to receive the maximum possible settlement offer or compensation from the insurance company, personal injury ICD codes must be included in the demand letters.

Both plaintiff and defense attorneys rely on medical review services to prove/defend claims for medical expenses in personal injury lawsuits.

  • Plaintiff attorneys strive to establish the fairness of the plaintiff’s claim
  • Defense attorneys try to reduce an award of damages by challenging the fairness of the medical bills or claim

Plaintiffs in a personal injury case may be able to recover the medical bills if they are found to be “reasonable” and incurred for “necessary” treatment. The testimony of a treating physician can help establish necessity. To show that the medical bills are reasonable, you may need the opinion or proof provided by a professional medical billing expert. There are some jurisdictions wherein paid medical bills are considered reasonable whereas some other jurisdictions demand expert evidence to prove that the claim is reasonable even if the insurer has fully or partly paid the bill.

On the defense side, attorneys strive to minimize verdicts for damages. Medical chart review helps identify inflated, unreasonable, and mistaken medical billings. A thorough analysis brings to light billing errors such as billing for services that were not performed; double billing or billing twice for the same service; typos; upcoding or entering a medical code for a more expensive service or procedure than the one which was provided; drugs or devices that had already been billed but were not dispensed; and unbundled charges i.e. charging separate fees for services provided at the same time and should have been billed under a single code. The medical review team includes medical billing experts who can identify whether the medical bills are unreasonable, i.e. they exceed the “usual,” “customary,” and “reasonable” rate for the billed service.

  • The charge is not the “usual” one if the bill reflects a higher charge than what the same physician recently charged other patients for the same procedure.
  • The charge is not “customary” if the bill shows a price higher than what is charged by other providers for the same services in the same geographic area.
  • A bill that is either unusual or not customary is not “reasonable” unless it is justified by some special circumstance.

e-codes for Injury Documentation

E-codes or external cause of injury codes are to be used when a patient presents to a healthcare provider with an injury. They describe the who, what, where, why, and how related to an injury event. These codes categorize injuries according to

  • Intent – whether unintentional, assault/homicide, suicide, or undetermined
  • Place of occurrence
  • Mechanism – such as motor vehicle, fall, poisoning)
  • Activity – walking, running etc.

e-codes are to be used when a diagnostic code indicates an injury. To ensure accurate and complete e-code data, the medical documentation must also be accurate and complete. For hospitals and other healthcare providers, e-codes help ensure timely insurance reimbursement. If e-codes are missing, as revealed during a medical chart review, payers may ask for additional information regarding the injury. Missing codes could delay reimbursement until the payer can determine whether there is another party responsible for the injury and resultant claim. The entire insurance reimbursement process becomes more efficient and simpler if the insurer is given accurate details such as where the patient was, what he/she was doing, and what caused the injury via e-codes.

An expert medical review team performs a detailed review of the medical records that would reveal inflated billing. They can determine whether the charges were assessed for medical services that were never provided or for medical equipment/drugs that were never dispensed. They can easily understand the medical coding systems that are used in medical billing. They compare the various services that are documented in the medical records to the medical codes that describe those services, and determine whether upcoding or unbundling led to an inflated medical bill.

The expert review team determines the usual, customary, and reasonable charges for services in a particular geographic area on the basis of databases and their own research. These databases contain valuable information regarding customary charges for various medical services. Typically, the charge for a medical service that is beyond a reasonable range of charges for that service is considered unreasonable.

Plaintiff as well as defense attorneys handling personal injury cases can benefit from an objective review of medical records and medical bills. It helps them understand whether the personal injury claim is reasonable or unreasonable. Medical review services can help plaintiff and defense lawyers present a successful case.

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