At the Prescott Pulse, we deeply appreciate our doctors, nurses, and first responders. Every day they show up to care for our community in Prescott and Yavapai County. But here’s an important truth: you are the expert on your own body. Don’t hesitate to ask questions, request clarification, and double-check what gets added to your permanent medical record. A simple conversation today can protect you for years to come.

This article was inspired by an email from one of our contributors. She shared the story of “Patient A,” a Prescott-area resident whose seven-month medical journey shows exactly why understanding ICD codes matters to all of us. It’s understanding the system our wonderful physicians are struggling to deal with so they get paid and you don’t have out of pocket expenses.

Patient A’s Seven-Month and Still Ongoing Ordeal

Last August, Patient A had an infiltrating basal cell carcinoma removed from above her right eye by, who we will call, Doctor B. The surgery left a large wound that required plastic surgery. When she returned to have the stitches removed, she mentioned a constant ache in her forehead and new rosacea-like symptoms on her forehead and nose.

The response was brief: “Talk to your GP about stress headaches.” She was given a cream for the rosacea. The headaches continued, and the cream didn’t help. In December, Patient A returned to Dr. B with the same, and now worsening, symptoms. This time, Dr. B’s nurse explained that headaches are common after this type of surgery because the supraorbital nerve (a sensory branch of the trigeminal nerve that supplies feeling to the forehead, upper eyelid, and scalp) had been disturbed during the procedure. She added that full healing can take 6 months.

By mid-January, still in pain, Patient A turned to her naturopathic doctor, (we’ll call her Dr. C), who has been her primary provider for 18 years. After hearing about the previous five months, Dr. C ordered blood work and prescribed gabapentin, a medication specifically used for nerve pain. For the first time in months, Patient A’s headaches eased, and the rosacea-like symptoms that had spread across her face and now through the scalp, have calmed down. The medication made daily life much easier while she waited for an appointment with a neurologist.

Patient A’s initial blood work came back within normal ranges, so Dr. C wanted to order additional lab tests to systematically find if the damaged nerve might not be the only root cause. Unfortunately, Dr. C’s practice is not affiliated with Medicare, so Patient A has to pay out of pocket. The cost of these extra tests was more than Patient A could comfortably afford. A friend recommended an allopathic (conventional) physician who bills Medicare and was accepting new patients.

During her first visit with the new doctor (we’ll call him Dr. D), Patient A described the now entire seven-month saga that began the day a large chunk of flesh was removed from her forehead, affecting the supraorbital nerve. She described Dr. D’s response as “dystopian.”

Within 15 minutes, he dismissed her belief that the surgery caused the headaches. He suggested a Kenalog (steroid) injection and a full series of allergy tests. When Patient A questioned the logic of doing allergy testing right after a strong immune-suppressing injection, Dr. D became unhappy and said he would order lab tests to reach a “real diagnosis.”

Here is what Dr. D ordered along with the ICD diagnosis codes attached to each test:

• CBC with Differential → E78.5 Hyperlipidemia

• LDL Cholesterol → E78.5 Hyperlipidemia

• Comprehensive Metabolic Panel → E78.5 Hyperlipidemia

• Lipid Panel with Ratio → E78.5 Hyperlipidemia

• Hemoglobin A1C → R73.09 Other abnormal glucose

• Magnesium → R25.2 Cramp and spasm

• TSH + Free T4 → E03.9 Hypothyroidism, unspecified (even though Patient A had normal results from the same test one month earlier)

• Urinalysis with Culture → R30.0 Dysuria (painful urination, a symptom she never reported)

• Sedimentation Rate → M79.1 Myalgia

• C-Reactive Protein → M79.1 Myalgia

• Sjögren’s Antibodies (Anti SS-A / SS-B) → M79.1 Myalgia

• CCP IgG Antibodies → M79.1 Myalgia

• ANA Comprehensive Panel → M79.1 Myalgia

• Rheumatoid Factor (IgA / IgM) → M79.1 Myalgia

All the tests billed under M79.1 Myalgia (muscle pain) were inflammation and autoimmune markers, such as those for Lupus, Sjögren’s syndrome, and Rheumatoid Arthritis.

What Those Codes Actually Mean and Why They Matter

ICD codes (International Classification of Diseases) are the standardized “language” doctors and billing offices use to tell insurance companies why a visit, test, or treatment was medically necessary. Once entered into your electronic health record, these codes become part of your permanent medical history.

ICD codes are diagnosis codes. They reflect what the doctor believes is wrong with the patient (or the reason for the service) at the time of billing. They are not used to “test for” a condition or to confirm a diagnosis.

Patient A chose not to complete those labs because the previous results from what Dr. C ordered were normal and she had none of the symptoms linked to the attached diagnoses. She worried that when these results came back negative, the original codes might never be updated or removed. Future insurance underwriters could then see a list of “pre-existing conditions” that made her appear to be a much higher risk than she actually is.

In this single visit, Patient A’s record could have been permanently tagged with conditions she does not have: high cholesterol, prediabetes (abnormal glucose), hypothyroidism, urinary pain (dysuria), chronic muscle pain (myalgia), and an autoimmune workup suggesting possible rheumatoid arthritis or Sjögren’s syndrome.

How This Affects You When Applying for Insurance

Life insurance underwriters are especially strict. Multiple unexplained diagnosis codes can result in:

• Higher premiums

• Postponed or declined coverage

• Exclusion riders that omit coverage for anything “related” to those codes

Health insurance is largely protected under the Affordable Care Act (no denial based on pre-existing conditions), but inaccurate codes can still lead to:

• Delayed or denied claims later on

• Higher out-of-pocket costs in employer or short-term plans

• Complications when switching insurers or moving to a Medicare Advantage plan

Even your future doctors may quickly scan your chart and assume you have conditions that were already ruled out.

What You Can Do Right Now

1. Ask questions at every visit. When a doctor orders tests, ask: “What ICD codes are you using and why?”

2. Review your Explanation of Benefits (EOB) every time one arrives in the mail or online portal.

3. Request your full medical record at least once a year (you are legally entitled to it).

4. Insist on corrections. If a test comes back negative, ask the provider to amend the record and remove or update the diagnosis code. Put the request in writing and keep a copy.

5. Bring a one-page summary of your medical history to new providers so they don’t start from scratch and over-code.

Patient A’s story is an extreme example, but it highlights why ICD codes deserve our attention. We also believe it is the exception, not the rule. We trust our medical teams, but the system moves quickly. Being an informed, confident patient helps everyone. Don’t hesitate to politely ask your providers to double-check the codes, especially when tests come back negative. They are there to protect your health and your medical record.

The Prescott Pulse aren’t physicians and please don’t consider this medical advice.