Chronic pain left the teenager “almost unable to do anything,” and his insurance company wouldn't cover the cost of the surgery.

When Preston Nafts was 12 years old, he asked his father for permission to play lacrosse.

“The first practice, he came back and said, 'Dad, I love you,'” recalled his father, Lothar Nafus, of Hoover, Alabama. “He lives for lacrosse.”

But years of youth sports had taken a toll on Preston's body. By the time he limped off the field at a lacrosse tournament last year, the pain in his left hip had become so severe that simple tasks like getting out of a car or rolling over in bed were difficult. Months of physical therapy and anti-inflammatory medications hadn't helped.

Not only did she have to give up sports, “I couldn't do much,” said Preston, now 17.

Medical Treatment

Doctors recommended Preston undergo sports hernia repair surgery to repair damaged tissue in her pelvis that is believed to be causing the pain.

The sports medicine clinic that treated Preston told Lauter that there was no medical billing code for the procedure — an identification code that health care providers use to bill insurers and other payers. It would likely be difficult to get insurance companies to cover the procedure, Lauter was told, so he would have to pay up front.

Lothar said the surgery was “necessary” because of the pain his son was in. He paid more than $7,000 to the clinic and surgery center on his personal credit card and a no-interest medical credit card.

Preston underwent surgery in November and his father filed a claim with his insurance company, hoping for a full refund, but was not paid.

Final invoice

The total was $7,105, broken down into $480 for anesthesia, $625 for facility fee and $6,000 for surgery.

Billing Issue: Missing CPT Code

Before his surgery, Lothar said he called Blue Cross Blue Shield of Alabama and was heartened to learn that his insurance covered most non-cosmetic medical procedures.

But during subsequent phone calls, he said, the insurance company representative “tried to make excuses and give me evasive excuses.” He said he called several times just before the surgery and was turned down.

Lothar said she trusted her son's doctor, who showed her studies showing the surgery works, and that the clinic, Andrews Sports Medicine and Orthopedic Center, has a good reputation in Alabama, she said.

Other medical providers not involved in this incident have performed the procedure. Fair Treatment.

Sports hernias, also known as “sports-induced pubic pain,” are a catch-all term for pain athletes experience in the lower groin or upper thigh, said David Geyer, an orthopedic surgeon and sports medicine specialist in Mount Pleasant, South Carolina.

“There are a lot of underlying factors that can contribute,” Geyer said, which is why “there's no one accepted procedure for this problem, and I think that's why there's no uniform CPT.”

CPT stands for “Current Procedural Terminology” and refers to numeric or alphanumeric codes that represent procedures or services performed in a clinical or outpatient setting. For example, there is a CPT code for a rapid strep test and different codes for various x-rays.

Without CPT codes, you may have problems with reimbursement because insurance companies base payment on the CPT codes that providers use on their billing statements.

There are more than 10,000 CPT codes, with hundreds more added each year by a special committee of the American Medical Association, explains Leonta Williams, director of education for the AAPC, formerly known as the American Academy of Professional Coders.

If the procedure in question is used frequently, a code is more likely to be suggested, she said.

Geyer said not many orthopedic surgeons in the United States perform sports hernia repairs, and some insurance companies consider the procedure .

Preston said her pain has improved since the surgery, but her recovery has been much longer and more painful than she expected.

Lothar said he had paid for the surgery by the end of April.

Solution

The billing statement from the surgery center indicates that the CPT code assigned to Preston's sports hernia repair was “27299,” which stands for “pelvic or hip surgery without a specific code.”

After submitting more paperwork to contest the denial, Lothar received a check from the insurance company for $620.26. Blue Cross Blue Shield would not say how it arrived at that amount or what expenses it would reimburse.

Lothar said he continues to receive confusing messages from insurance companies about his claim.

Both the insurance company and the sports medicine clinic declined to comment.

summary

Before undergoing a medical procedure, check to see if your insurance company will cover the cost and make sure they have a billing code.

AAPC's Williams suggests asking your insurance company: “Will you reimburse for this code? What type of service falls under this code? What are the chances of getting reimbursed?”

Williams said it's difficult, but not impossible, to convince insurance companies to pay for procedures that don't have their own billing codes. Doctors can bill insurers using “unlisted codes” and documentation explaining what procedure was performed.

“Any time you're dealing with an unlisted code, it requires additional work to explain what service was provided and why it was necessary,” she said.

Some patients who undergo procedures without CPT codes may be asked to pay up front, and partial prepayments can be offered, which may incentivize providers to work together to get the insurance company to pay them.

This month's bill is a crowdsourced investigation. KFF Health News and Washington Post Wellbeing A series that breaks down and explains the cost of healthcare. Since 2018, the series has helped many patients and readers reduce their healthcare costs and has been cited in state legislatures, on Capitol Hill, and in the White House. Do you have a confusing or exorbitant medical bill you'd like to share? please tell me!

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