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Deciphering Medical Bills, a primer for attorneys

Dawn Cook Consulting is often asked to review and evaluate medical bills that have accumulated since an accident or for an incident that is in litigation. The process is often more complicated then simply looking at the medical coding or the medical records. Below we will highlight each step and demonstrate why it is important to have an experienced team conduct the review to best aid your case.

The first step in evaluating the bills is to determine if they are in fact related to the accident or incident. Things we look out for include bills for other concurrent conditions or subsequent conditions not related to the incident.

Next, were the codes correct for the care given? Many medical bills have a Current Procedural Terminology (CPT[1]) code. A five digit numerical code assigned that corresponds with physician care and surgery, and for labs, radiology, therapy and a few other medical services. Surgical codes include several procedures bundled together and a determination must be made on bundling of codes into one code or if add-on codes are justified. There are also different rates of pay for assistants to the surgeon, if they are needed.

Past medical bills also include charges for facility care; this may be Diagnosis Related Groups (MS-DRGs[2]) for in-patient visits and CPT codes for outpatient facility care. Many times there are charges for implants but these items are included in the code for implanting the item. There may also be bills for prescription medications, equipment and supplies; each has its own code or description.

The final step in reviewing past medical bills is to compare the codes and descriptions to the usual, reasonable and customary (URC) cost[3] for the care in the community where it was received. There are many sources for determining each type of cost, in databases[4] or Internet[5] sources with adjustments made for geographic areas.

The job for the law firm is to determine if the bills seem reasonable, or if they would like the bills evaluated by a professional. At Dawn Cook Consulting, we have an experienced team of nurses, coders and medical cost analyzers who can prepare a past medical bill review to better understand your case.

[1] American Medical Association (AMA): CPT® (Current Procedural Terminology). (2018). Retrieved May 20, 2018, from https://www.ama-assn.org/practice-management/cpt-current-procedural-terminology

[2] http://www.cms.gov

[3] HealthCare.gov Glossary: UCR (Usual, Customary, and Reasonable). (n.d.). Retrieved May 20, 2018, from https://www.healthcare.gov/glossary/UCR-usual-customary-and-reasonable/

[4] http://pmiconline.stores.yahoo.net/mefe20.html

[5] https://ahd.com/