The ABCs of ICDs


Tony Singleton | CEO | Turnberry | mail me |

Understanding ICD-10 codes is vital to effectively manage one’s medical and financial affairs.

You’ve probably heard about ICD-10 codes somewhere in conversations with your Medical Aid company or perhaps your insurance broker, but for many of us, the realm of ICD-10 codes remains a mysterious one blanketed in confusion.

ICD-10 codes are an internationally-recognised system that translates medical conditions into specific codes. They allow the likes of Medical Aids and Gap Cover providers to understand the reasons for certain treatments, procedures and hospital admissions – and ensure that 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 Aid benefits last longer, and to avoid claims being delayed or even completely rejected.

In our opinion, your Medical Aid and Gap Cover combination represents one of the most important types of insurance that you have. Yet we find people generally know too little about how to extract most value from their benefits. We feel that is essential that your medical financial planning forms part of your overall financial management.

Common issue

Clerical issues can certainly happen anytime, 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 absolutely no impact on the actual medical care that you receive, but they can have big implications in your medical financial affairs. For example, a colonoscopy may be mis-labelled 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 Aid, and they pay for it, so the customer doesn’t think anything more of it. But in fact, a portion of the  funds have been taken from one’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 may not need to – leaving them without those savings funds available later in the year.

Source of truth

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’ (cover than Medical Aids are obliged by law to offer).

However, in order to ensure that it’s processed as a Prescribed Minimum Benefit with the correct ICD-10 code, you may need to go to certain hospitals belonging to an approved network (depending on the specific medical aid plan that you’re on).

Without proper planning, you may accidently choose the wrong hospital, and end up with the wrong codes being applied, or being left with out-of-pocket expenses.

So, just where should customers go to find out exactly what codes should reflect on doctors’ invoices to their Medical Aid?

Consumers should draw on the knowledge of their financial advisor or medical aid, who would usually be able to confirm what is the correct ICD-10 code.

Getting to know ICD-10 codes may not be the most enthralling prospect, but ultimately, without a thorough understanding of which code should applies to which diagnosis you could potentially be decreasing your medical aid benefit.



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