In chronic pain, this young boy “couldn’t do anything.” Insurers will not cover the surgery.

When Preston Nafz was 12, he asked his father for permission to play lacrosse.

“The first practice, he came back, he said, ‘Dad, I like it,'” recalled his father, Lothar Nafz, of Hoover, Alabama. “He lives for lacrosse.”

But years of youth sports took a toll on Preston’s body. When the teenager limped off the field during a lacrosse tournament last year, the pain in his left hip had become so severe that he had trouble doing simple activities, such as getting out of the car or turning over in bed. Months of physical therapy and anti-inflammatory drugs didn’t help.

Not only did he have to give up sports, but “I could barely do anything,” says Preston, now 17.

Medical Procedures

Doctors recommended Preston undergo a procedure called a sports hernia repair to repair the damaged tissue in his pelvis, which he believed was causing the pain.

The sports medicine clinic that treated Preston told Lothar that the procedure did not have a medical billing code — an identifier that providers use to bill insurance and other payers. It will likely be a struggle to persuade insurance companies to cover it, Lothar said, so they have to pay up front.

With his son suffering, Lothar said, the operation “had to be done.” He paid more than $7,000 to clinics and surgery centers with personal credit cards and medical credit cards with zero interest rates.

Preston had surgery in November, and his father filed a claim with his insurance company, hoping to get a refund. Absence.

Final bill

$7,105, which is broken down as $480 for anesthesia, $625 in facility fees, and $6,000 for surgery.

Billing Problem: No CPT Code

Before the surgery, Lothar said, he called Blue Cross and Blue Shield of Alabama and was encouraged to learn that their policies usually cover medical, non-cosmetic procedures.

But during a follow-up call, he said, the insurance representative “was distracted, trying to interrupt.” He said he called her several times, asking her to turn him down before surgery.

Lothar said he trusted his son’s doctor, who showed him research that showed the surgery. The clinic, Andrews Sports Medicine and Orthopedic Center, has a good reputation in Alabama, he said.

Another medical provider not involved in the case called surgery a legitimate treatment.

Sports hernia — also known as “athletic pubalgia” — is an apt phrase to describe the pain that athletes may experience in the groin or upper thigh area, says David Geier, an orthopedic surgeon and sports medicine specialist in Mount Pleasant, South Carolina. . .

“There are some basic things that can cause it,” Geier said. Because of that, no one “received surgery for that problem. That’s why I suspect there is no uniform CPT.”

CPT stands for “Current Procedural Terminology” and refers to numeric or alphanumeric codes for procedures and services performed in a clinical or outpatient setting. There are CPT codes for rapid strep tests, for example, and different codes for various X-rays.

The lack of CPT codes can cause reimbursement headaches, as insurance companies determine how much to pay based on the CPT codes the provider uses on the claim form.

More than 10,000 CPT codes exist. Several hundred are added each year by a special committee of the American Medical Association, explains Leonta Williams, director of education at the AAPC, formerly known as the American Academy of Professional Coders.

More codes could be proposed if the procedure is used too much, he said.

Not many orthopedic surgeons in the U.S. perform sports hernia repairs, Geier said. He said some insurance companies consider the operation an experiment.

Preston said the pain has improved since the surgery, although the recovery took longer and was more painful than expected.

By the end of April, Lothar said, he had finished paying for the surgery.

Resolution

A billing statement from the surgery center shows that the CPT code assigned to Preston’s sports hernia repair is “27299,” which stands for “pelvic or hip joint procedures that do not have a specific code.”

After submitting more documentation to appeal the insurance denial, Lothar received a check from the insurance company for $620.26. Blue Cross and Blue Shield did not say how they came up with the number or which reimbursement costs.

Lothar said she continues to receive confusing messages from her insurance company about her claim.

The insurer and the sports medicine clinic declined to comment.

The Takeaway

Before undergoing a medical procedure, try to make sure that your insurance company will cover the cost and confirm that there is a billing code.

AAPC’s Williams recommends asking your insurer: “Do you reimburse this code? What types of services are included in this code? What is the likelihood that this will be reimbursed?”

Getting insurance companies to pay for care that doesn’t have its own billing code is difficult but not impossible, Williams said. Your doctor may provide insurance using an “unregistered code” along with documentation that explains what procedure was performed.

“Whenever you’re dealing with an unregistered code, there’s additional work required to explain what services they provide and why they’re needed,” he said.

Some patients undergoing procedures without a CPT code may be asked to pay in advance. You can also offer a partial down payment, which can motivate your provider to pay for insurance.

Bill of the Month is a crowdsourced investigation by KFF Health News and The Washington Post’s Well+Being that dissects and explains medical bills. Since 2018, this series has helped many patients and readers to reduce medical bills, and has been mentioned in statehouses, the US Capitol, and in the White House. Do you have confusing or outrageous medical bills that you want to share? Tell us about it!

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