Diagnostic Codes Are More Than Just An Accounting Tool by Jill Gambaro

by Jill Gambaro

If you’ve ever looked at a medical bill, you’ve seen those mysterious numbers that appear after the even more mysterious descriptions of services rendered. These are diagnostic codes and they are used to describe diagnosis, treatment and how the facility should bill for those services. But when you’re a patient, those seemingly innocent codes wind up controlling a lot more than how much your practitioner gets to charge your insurance company.

Each diagnostic code has been carefully argued, discussed and peer reviewed by medical professionals. They include not only a diagnosis but also the recommended treatment and duration for that treatment. When you contract an injury or illness that medical science does not yet understand, this is where diagnostic codes can become trouble. In an effort to reach consensus, treatments and duration are often reduced to the most common denominator. Except, as we all know, when it comes to the human body, very little is ‘most common’.

When my doctor first pronounced me unable to work, or temporarily totally disabled, and the workers’ compensation insurance company who was supposed to provide me with disability benefits refused, the State of California stepped in. California, as well as many other states, offers their own temporary disability benefits. Those benefits are most often used by pregnant women taking maternity leave, but I was also eligible to receive them. The less than $100 per week I received was my only income at the time and I desperately needed it. Unfortunately, the diagnostic code for carpal tunnel syndrome described treatment was only necessary for 21 days, so after jumping through all the hoops to receive this benefit in the first place, I was quickly cut off. I called the State and was told I could appeal the decision before an administrative law judge to do that. I scheduled a hearing.

Before being injured, I worked in law, so I prepared for the hearing out of experience. I gathered evidence of how many carpal tunnel sufferers did not heal within three weeks, how treatments prescribed in diagnostic codes was inadequate and anything else I could come up with. When it came time for the hearing, I was more than prepared. The State of California sent a seemingly nice man in a modest suit to present their case. And then I cross-examined him. I mean Perry Mason cross-examined him. It wasn’t long before the administrative law judge, eyebrows raised, looked through my file as I pummeled the State's representative with questions, pacing the entire time because I was in too much pain to sit. Clearly, I knew far more about carpal tunnel syndrome than the State's representative did. The Judge raised his hand and said, “wait a minute. You were a legal secretary in Beverly Hills when you got injured? You can’t be faking it, you were making too much money. Her benefits are reinstated.” And that was the end of that.

After spending months getting stonewalled at nearly every turn, this small victory was huge for me. It gave me the courage to keep on fighting against the system. To make sure I received the treatment needed to recover. In the end, I wasn’t that successful, I simply got out with the skin still on my nose, but most others faired far worse. In T. Harv Eker's book Secrets of the Millionaire Mind, he says rich people believe they are bigger than their problems, while the poor and middle class believe their problems are bigger than they are. Once I took the time to research and understand my injury, I found everything changed for me. I became my own best advocate, a partner with my practitioners in my recovery. They, in turn, began to go the extra mile for me. It made all the difference in my ability to regain control over my life.

Keywords: diagnostic codes, healthcare system, patient advocacy