By Elizabeth Davis, RN. Health Insurance Expert
Updated July 26, 2015.
Although a procedure sounds like a series of steps you have to follow to accomplish a task, that’s not exactly what it means when used in the context of health insurance. When your health insurance company talks about a medical procedure, it’s talking about something that can be done to your body, not about a series of steps.
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Pretty much anything that a health care provider can do to your body could be considered a type of procedure. Medical procedure types include
- Diagnostic procedures
- Surgical procedures
- Non-surgical therapeutic procedures
- Rehabilitative procedures
- Propaedeutic procedures
Some medical procedures can even fit into more than one of these groupings.
Diagnostic procedures are used by health care providers to help figure out if something is wrong with you, and if so, what’s wrong. This type of medical procedure includes medical imaging tests like X-rays, MRI scans, and ultrasounds as well as other familiar tests like blood tests and electrocardiograms or ECGs.
However, some diagnostic procedures are more invasive than X-rays and ultrasounds. For example, a colonoscopy could be considered a diagnostic procedure if the gastroenterologist is doing it to find out if you have a problem with your colon.
Surgical procedures involve cutting the body. Common surgical procedures include having your gallbladder removed. known as a cholecystectomy, and having a heart bypass. known as a coronary artery bypass graft. However, surgical procedures don’t necessarily have to involve general anesthesia, lots of stitches, and a long recovery time.
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For example, removing a mole may only take a few seconds with a scalpel in the dermatologist's office, but it’s still a surgical procedure.
Non-Surgical Therapeutic Procedures
A non-surgical therapeutic procedure is a medical procedure used to treat a health problem. Have you ever seen someone with asthma or emphysema get a nebulized breathing treatment. That breathing treatment is a therapeutic procedure. Have you known someone who needed dialysis because their kidneys weren’t filtering the wastes from their blood? Dialysis is a non-surgical therapeutic procedure. Radiation therapy used to treat
cancer is another example of a non-surgical therapeutic procedure.
Rehabilitative procedures might be considered their own class of medical procedure, but could also be considered a subset of therapeutic procedures. Rehabilitative procedures are used to help people regain, maintain, or improve the function of a body part. Physical therapists. occupational therapists. and speech therapists specialize in rehabilitative procedures. Rehabilitative procedures also include lesser-known medical procedures such as the Epley’s maneuver .
I consider propaedeutic procedures to be somewhat akin to a preamble. They’re simple, everyday medical procedures done as a basic part of almost every single patient encounter. Propaedeutic procedures include things like checking a patient’s blood pressure, temperature, and heart rate. Listening to a patient’s lungs or abdomen with a stethoscope and palpating, or feeling a patient’s body with your hands, are also considered propaedeutic procedures.
Procedures That Fit Into More Than One Group
Some procedures fit into more than one group. For example, when a dermatologist takes a biopsy of a suspicious-looking mole, the biopsy can be considered both a diagnostic procedure and a surgical procedure. The dermatologist is doing the biopsy to figure out what’s wrong; that means it’s a diagnostic procedure. However, if the biopsy requires cutting a small piece of skin off of your body, it’s also a surgical procedure.
Why Procedures Matter in Health Insurance
Money is the simple reason why medical and surgical procedures matter in health insurance. Other than propaedeutic procedures, almost all medical procedures will be billed for. In fact, there are entire medical billing code sets dedicated to billing for procedures. In the United States, CPT or HCPCS codes are used to designate procedures. Starting October 1, 2015, ICD-10-PCS codes will be used to designate procedures done on hospitalized inpatients.
Since procedures tend to be more expensive than other billable health care, health insurance companies give procedures extra scrutiny to make sure they’re really medically necessary. Managed care health plans frequently require that their members get prior authorization for expensive surgical, diagnostic, and therapeutic procedures. If you’re required to get a procedure pre-authorized but don’t, your insurance company has the right to refuse to pay for the procedure even if you really needed it.