Amy Ray vs. Allstate Fire and Casualty Insurance Company

The materials and resources used in this analysis include the past medical records and medical billing data for Amy

Ray for her treatment. The sonable value of past medical care is determined by an analysis of both the billing and

coding rules and then the comparison of geographic specific pricing data. The analysis uses national sources listed

in the source section below. It is inclusive of national rules, standards, and federal regulations which dictate how

medical services are billed in the United States. The national pricing databases provide geographic specificity

correlated to the category of medical care received. This analytical system has existed in the health care industry for

decades.

Each category of care has its own unique medical billing code set that transforms descriptions of services into

numerical medical codes that create the common language in the health care industry. Each code set contains

highly defined rules and regulations that dictate their use, and exists in unique, geographic specific pricing

databases.

The International Classification of Diseases (ICD) is the diagnostic code set which specifies the reason that a patient

seeks medical care. The current code set is ICD 10; prior to October 2015, the code set was ICD 9.

The categories of medical care and corresponding code sets are:

Professional and Anesthesia Services CPT (Current Procedural Terminology) codes describe medical, surgical,

diagnostic, and anesthesia services.

Inpatient Hospitalization: DRG (Diagnosis Related Group) codes identify inpatient hospital services.

Outpatient Facilities: APC (Ambulatory Payment Classification) codes identify outpatient facility services and are

applied based on CPT codes.

Pharmaceuticals: National Drug Codes identify prescribed drugs/medications.

Durable Medical Equipment, Prosthetics, Orthotics, Supplies and Biologics: HCPCS (Healthcare Common

Procedure Coding System) codes are used for these dispensed products.

Dental: CDT (Current Dental Terminology) codes describe dental medical, surgical, and diagnostic services

Process

submitted medical bills and medical records are organized, reviewed, and analyzed to confirm that services

after the date of injury were injury related charges and that the charges were based on proper medical coding.

Additionally, the medical and billing records are reviewed for completeness, and any identified missing records are

noted in the Missing Records section of this report.

After the organizational abstract is prepared, the medical and billing records are carefully reviewed, and the

following data points (when available) are entered onto a spreadsheet based on:

Provider of care

Date of service

Description of service

Amount charged

Diagnosis Codes ICD 9, ICD 10

Code Sets CPT, HCPCS, APC, DRG and NDC