When Preston Nafz was 12, he asked his dad for permission to play lacrosse.<\/p>\n
\u201cFirst practice, he came back, he said, \u2018Dad, I love it,\u2019\u201d recalled his father, Lothar Nafz, of Hoover, Alabama. \u201cHe lives for lacrosse.\u201d<\/p>\n
But years of youth sports took a toll on Preston\u2019s body. By the time the teenager limped off the field during a lacrosse tournament last year, the pain in his left hip had become so intense that he had trouble with simple activities, such as getting out of a car or turning over in bed. Months of physical therapy and anti-inflammatory drugs didn\u2019t help.<\/p>\n
Not only did he have to give up sports, but \u201cI could barely do anything,\u201d said Preston, now 17.<\/p>\n
The Medical Procedure<\/strong><\/p>\n A doctor recommended Preston undergo a procedure called a sports hernia repair to mend damaged tissue in his pelvis, believed to be causing his pain.<\/p>\n The sports medicine clinic treating Preston told Lothar that the procedure had no medical billing code \u2014 an identifier that providers use to charge insurers and other payers. It likely would be a struggle to persuade their insurer to cover it, Lothar was told, which is why he needed to pay upfront.<\/p>\n With his son suffering, Lothar said, the surgery \u201cneeded to be done.\u201d He paid more than $7,000 to the clinic and the surgery center with a personal credit card and a medical credit card with a zero-interest rate.<\/p>\n Preston underwent surgery in November, and his father filed a claim with their insurer, hoping for a full reimbursement. It didn\u2019t come.<\/p>\n\n The Final Bill<\/strong><\/p>\n $7,105, which broke down as $480 for anesthesia, a $625 facility fee, and $6,000 for the surgery.<\/p>\n The Billing Problem: No CPT Code<\/strong><\/p>\n Before the surgery, Lothar said, he called Blue Cross and Blue Shield of Alabama and was encouraged to learn that his policy typically covers most medical, non-cosmetic procedures.<\/p>\n But during follow-up phone calls, he said, insurance representatives were \u201cdeflecting, trying to wiggle out.\u201d He said he called several times, getting a denial just before the surgery.<\/p>\n Lothar said he trusted his son\u2019s doctor, who showed him research indicating the surgery works. The clinic, Andrews Sports Medicine and Orthopaedic Center, has a good reputation in Alabama, he said.<\/p>\n Other medical providers not involved in the case called the surgery a legitimate treatment<\/a>.<\/p>\n A sports hernia \u2014 also known as an \u201cathletic pubalgia\u201d \u2014 is a catchall phrase to describe pain that athletes may experience in the lower groin or upper thigh area, said David Geier, an orthopedic surgeon and sports medicine specialist in Mount Pleasant, South Carolina.<\/p>\n \u201cThere\u2019s a number of underlying things that can cause it,\u201d Geier said. Because of that, there isn\u2019t \u201cone accepted surgery for that problem. That\u2019s why I suspect there\u2019s not a uniform CPT.\u201d<\/p>\n CPT stands for \u201cCurrent Procedural Terminology\u201d and refers to the numerical or alphanumeric codes for procedures and services performed in a clinical or outpatient setting. There\u2019s a CPT code for a rapid strep test, for example, and different codes for various X-rays.<\/p>\n The lack of a CPT code can cause reimbursement headaches, since insurers determine how much to pay based on the CPT codes providers use on claims forms.<\/p>\n More than 10,000 CPT codes exist. Several hundred are added each year by a special committee of the American Medical Association, explained Leonta Williams, director of education at AAPC, previously known as the American Academy of Professional Coders.<\/p>\n Codes are more likely to be proposed if the procedure in question is highly utilized, she said.<\/p>\n Not many orthopedic surgeons in the U.S. perform sports hernia repairs, Geier said. He said some insurers consider the surgery experimental.<\/p>\n Preston said his pain improved since his surgery, though recovery was much longer and more painful than he expected. <\/p>\n By the end of April, Lothar said, he\u2019d finished paying off the surgery.<\/p>\n The Resolution:<\/strong> A billing statement from the surgery center shows that the CPT code assigned to Preston\u2019s sports hernia repair was \u201c27299,\u201d which stands for \u201ca pelvis or hip joint procedure that does not have a specific code.\u201d<\/p>\n After submitting more documentation to appeal the insurance denial, Lothar received a check from the insurer for $620.26. Blue Cross and Blue Shield didn\u2019t say how it came up with that number or which costs it was reimbursing.<\/p>\n Lothar said he has continued to receive confusing messages from the insurer about his claim.<\/p>\n Both the insurer and the sports medicine clinic declined to comment.<\/p>\n The Takeaway<\/strong><\/p>\n Before you undergo a medical procedure, try to check whether your insurer will cover the cost and confirm it has a billing code.<\/p>\n Williams of the AAPC suggests asking your insurer: \u201cDo you reimburse this code? What types of services fall under this code? What is the likelihood of this being reimbursed?\u201d<\/p>\n Persuading an insurer to pay for care that doesn\u2019t have its own billing code is difficult but not impossible, Williams said. Your doctor can bill insurance using an \u201cunlisted code\u201d along with documentation explaining what procedure was performed.<\/p>\n \u201cAnytime you\u2019re dealing with an unlisted code, there\u2019s additional work needed to explain what service was rendered and why it was needed,\u201d she said.<\/p>\n Some patients undergoing procedures without CPT codes may be asked to pay upfront. You can also offer a partial upfront payment, which may motivate your provider to team up to get insurance to pay.<\/p>\n Bill of the Month is a crowdsourced investigation by KFF Health News<\/a> and The Washington Post\u2019s Well+Being<\/a> that dissects and explains medical bills.\u00a0Since 2018, this series has helped many patients and readers get their medical bills reduced, and it has been cited in statehouses, the U.S. Capitol, and at the White House. Do you have a confusing or outrageous medical bill you want to share? Tell us about it<\/a>!<\/em><\/p>\n KFF Health News<\/a> is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF\u2014an independent source of health policy research, polling, and journalism. Learn more about KFF<\/a>.<\/p>\nUSE OUR CONTENT<\/h3>\n