Standard of Care-How Drs Must Operate
Posted , 3 users are following.
In the US where private insurance covers at least a majority of folks, doctors must operate under what is termed "standard of care." This means that for Disease A, there is a prescribed medical billing code for which the insurance will cover and the doctor will not likely be sued. In the law, if a dr. strays too far outside the "standard treatment for disease A," and something goes wrong, guess what happens to said dr.?
The disease or condition must be recognized under the International Classification of Diseases, or ICD-10, from the World Health Organization. When we present with vague symptoms or symptoms that don't easily put us into category for Disease A, the doctor is in a quandary. They want the insurer to cover their office visit and any tests or procedures so they have to use the correct code. Every recognized disease has a code. You can look this up and actually see all the codes. If the doctor's office puts down the wrong code and insurance doesn't recognize it, the computer software for medical billing will reject the claim until the right codes are entered.
I think this is one reason we are not getting the care we should. LS has no real cause and is often difficult to diagnose. I am still looking through articles for a clearer cause/treatment
0 likes, 5 replies
susan43705 Guest
Posted
Thank yo.u for clarifying that.
Guest susan43705
Posted
Been researching. So far found article in the Lancet (Britain) from 2003 that said 67% of LS skin samples contained Immunoglobulin G, one of the AI tests. These researchers tested 86 women and found abnormal accumulation of proteins in the tissues of LS sufferers. What does this mean? Unsure but I keep finding a stronger link between LS and autoimmune. All the journals I read say this.
susan43705 Guest
Posted
I'm taking this information to my primary for more intensive testing. Thank you for this information. Isn't eczema, psoraris and hives an AI disease?
beverly52803 Guest
Posted
Thanks for that. So, if we have been diagnosed with LS is it safe to assume there is a code for that.
I'm wondering about codes for acceptable treatments for that disease. For instance the PRP injections. Do health insurance companies consider that an acceptable treatment for any condition? I know athletes are getting them for injuries and am curious if injections are covered for them.
It seems pretty clear they will not be covered for LS as we are all told steroids are the only successful treatment. One office I called re the PRP explained the procedure would have to be paid for by me but I would be given all the proper codes and paper work by the staff to submit to my insurance co for reimbursement. When I asked how much luck any patients were having with that the answer was "none".
I googled World Health Organization, International Classification of Diseases and came up with the ICD-11. There is a code for Diseases of the Immune (04) as well as Diseases of the skin (14), Conditions Related to Sexual Health (17), Under Coded Elsewhere "changes in female anatomy" is listed but has no number. Typed in lichen sclerosis and came up with EB60.0
Although they reference ICHI (International Codes of Health Interventions) I got lost in the weeds there. Not sure how to find actual treatment names.
Guest beverly52803
Posted
ICD-10 was implemented in 2017. I think the 11s are still being worked out.
Whether a provider wants to figure out the codes or not has always been one of my questions as I've seen lots of mistakes. I will have to look up LS and that EB60.
Stay tuned.