Eleanor Finch
The billing process for a physician's office visit can vary depending on the nature of the visit, the type of medical practice, and the patient's insurance plan. Typically, during an office visit, patients are charged for the physician's examination, with a co-payment collected at check-in. However, the billing process can become more complex when procedures or additional services are involved. Medicare billing, for instance, has specific guidelines for what constitutes an initial visit and how to bill for both preventive and evaluation and management (E/M) services during the same visit. Physicians must accurately document and bill for the services provided to avoid issues with reimbursement and compliance.
| Characteristics | Values |
|---|---|
| Location | Physician's office or hospital outpatient location |
| Type of visit | First visit, new patient visit, or subsequent visit |
| Type of patient | Medicare beneficiary |
| Type of procedure | Evaluation and management (E/M) service, preventive medicine service, or procedure |
| Time spent | 40-45 minutes |
| Billing code | 99112, 51784, 90912, 99215, 99213 |
| Payment method | Co-payment, insurance, or out-of-pocket |
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What You'll Learn
Medicare billing for an initial visit
An initial Medicare visit is classified as a 'Welcome to Medicare' preventive visit. This is a patient's first visit to a practice or physician and can be billed as a new patient visit. During this appointment, the patient's doctor or healthcare provider will review their medical and social history, including their family health history, and provide information about preventive services, including screenings, shots, and vaccines. The provider will also review the patient's potential risk factors for substance use disorder and offer referrals for treatment if necessary.
For this type of visit, patients are advised to bring their medical records, including immunization records, a list of current prescriptions, and over-the-counter drugs, vitamins, and supplements they are taking, along with details of how often they take them and why. If the patient has a current opioid prescription, the provider will review their potential risk factors for opioid use disorder and evaluate their pain and treatment plan.
In terms of billing, if the doctor or healthcare provider accepts assignment, the patient will not have to pay for the visit. However, the patient may have to pay coinsurance, and the Part B deductible may apply if additional tests or services are performed during the visit that Medicare does not cover. If Medicare does not cover these additional services, such as a routine physical exam, the patient may have to pay the full amount.
It is important to note that Medicare beneficiaries who visit a hospital outpatient location will be responsible for a Medicare Part B out-of-pocket co-insurance payment of approximately $25 for the hospital facility charge. Additionally, if a procedure is performed during a physician office visit, there may be further out-of-pocket costs for additional physicians' services and the use of hospital facilities and staff.
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Physician office vs. hospital outpatient visit
When it comes to physician office visits and hospital outpatient visits, there are some key differences in billing that patients should be aware of. Typically, a physician's office visit will result in a single charge for the physician's examination, which is usually covered by the patient's co-payment. This co-payment is often the only out-of-pocket cost for the patient.
On the other hand, a hospital outpatient visit usually incurs two charges: one for the physician's examination, which is again typically covered by the co-payment, and a second charge from the hospital for the use of their facilities, equipment, and support staff, known as a "Facility Fee". This second charge can result in higher out-of-pocket costs for the patient compared to a physician's office visit.
For Medicare beneficiaries, a hospital outpatient visit will often include a Medicare Part B out-of-pocket co-insurance payment of approximately $25 for the hospital facility charge. Procedure charges and additional testing can further increase these out-of-pocket expenses. It is important to note that insurance plans vary, and some insurance companies may cover both hospital and physician charges, while others may not.
In both physician office and hospital outpatient visits, patients may require a referral or authorization from their health insurer. Additionally, the classification of providers as "In Network" or "Out of Network" can impact the final cost for the patient. If a procedure is performed during the visit, patients may also be responsible for additional out-of-pocket costs for physician services and the use of hospital facilities and staff, regardless of the location. These charges may be applied to the patient's annual deductible, and after this deductible is met, further co-insurance payments may be required.
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The impact of procedure length
When it comes to office visits, the Current Procedural Terminology (CPT) guidelines play a crucial role in determining the billing codes and, consequently, the reimbursement rates. CPT codes are regularly updated to reflect the current clinical practices and innovations in medicine. For instance, CPT codes 99213, 99214, and 99215 correspond to established patient office visits, with the latter indicating a longer duration of 40 minutes or more.
The duration of a procedure can influence the billing in several ways. Firstly, longer procedures may warrant a higher billing code, resulting in increased reimbursement for the physician. This is particularly relevant when the procedure involves complex decision-making, counselling, or interpreting results, as these activities are considered in determining the appropriate billing code.
Secondly, the length of the procedure can impact the patient's out-of-pocket costs. While a physician's office visit typically incurs only the physician's examination fee, procedures performed during the visit may result in additional charges. These can include fees for the use of hospital facilities, equipment, and support staff, often referred to as "Facility Fees."
Moreover, the duration of the procedure can also influence the billing when it comes to preventive and evaluation and management (E/M) services. In some cases, physicians may encounter challenges when billing for both acute or chronic care and preventive services during the same visit. The CPT guidelines provide clarification on this issue, stating that if a significant problem or abnormality is addressed during a preventive visit, requiring additional work, then the appropriate E/M code should also be billed.
It is worth noting that the CPT guidelines allow physicians to bill based on either medical decision-making (MDM) or the total time spent on the encounter. MDM includes establishing diagnoses, assessing the condition, and selecting a management option. When billing based on time, the CPT Evaluation and Management (E/M) Code and Guideline Changes provide specific durations of time for billing, helping physicians determine the appropriate code.
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Billing for multiple services in one visit
When it comes to medical billing, an office visit typically refers to a patient's examination by a physician in their office. This usually incurs a charge for the physician's services, which is often covered by the patient's co-payment. However, in the case of billing for multiple services during a single office visit, there are a few considerations to keep in mind.
Firstly, it is important to understand the concept of "multiple services." This can refer to two evaluation and management (E/M) services provided on the same day, a procedure accompanied by an E/M service, or two or more procedures performed by the same physician during a patient encounter. Billing for multiple services in one visit is allowed and can provide benefits such as improved patient satisfaction and overall patient care.
When billing for multiple services, it is crucial to use the appropriate modifiers. Modifier 25, for instance, indicates a significant, separately identifiable E/M service provided by the same healthcare professional on the same day. This modifier can be appended to an E/M service code to distinguish it from other services provided during the same visit. Additionally, creating custom billing codes can help streamline the process. These codes can be internal or assigned by the payer or insurance company.
In certain cases, billing for multiple E/M visits on the same day for the same patient may be restricted by payer rules. If a patient is seen twice on the same day for related problems, the services should be combined and reported under a single E/M code. However, if the visits are for unrelated problems, the physician must document this, and billing for two E/M codes may be permissible.
It is essential to follow payer rules and documentation requirements when billing for multiple services in one visit. Understanding the nuances of CPT nomenclature and the appropriate use of modifiers can help ensure accurate billing and reimbursement. Proper reporting of multiple services can lead to improved patient care and satisfaction.
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In-network vs. out-of-network providers
When you enroll in health or dental insurance, you receive an insurance card that provides information about your coverage, including details of "in-network" and "out-of-network" healthcare providers.
A provider network is a list of the doctors, health care providers, and hospitals that an insurance plan contracts with to provide medical care to its members at agreed-upon prices. Providers who accept these contracts are called "in-network providers". When an insurance company partners with a provider, the provider agrees to a negotiated, discounted rate for services provided to the member. This negotiated rate is agreed upon before the service is provided. In-network doctors and facilities have agreed not to charge you more than the agreed-upon cost.
If a provider isn’t under contract with your plan, they are known as an “out-of-network provider”. When a doctor treats a patient who does not belong to their insurance network, they bill for those services as "out of network". This means the insurance company and the patient have not already agreed to a contracted rate for that doctor’s fees. The doctor can then charge their full, typical price for the care provided. For the patient, this often means higher out-of-pocket costs. Out-of-network providers may also work with out-of-network labs, and they may operate out of an out-of-network facility, such as a hospital or outpatient center where they perform surgeries.
In most cases, it is more cost-effective to choose an in-network provider. However, there can be situations when an individual chooses to use an out-of-network insurance provider. For example, you may want to continue seeing a healthcare provider that you have an established relationship with, even if they’re no longer within your network. This can be particularly beneficial if you’re managing a long-term medical condition. If it’s medically necessary for you to go out of network, chances are you’ll be covered for part or all of the bill.
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Frequently asked questions
When your visit takes place at a physician's office, you will usually be charged only for the physician's examination, and your co-payment will be your only out-of-pocket cost. For a hospital outpatient visit, there will typically be two charges: the physician's examination and a facility fee for the use of hospital space, equipment, and support staff.
An initial visit for Medicare billing is when a patient has not had a face-to-face visit with a specialist in the past 3 years.
Yes, physicians can bill for both preventive and evaluation and management (E/M) services in the same visit. Modifier-25 should be added to the office/outpatient code to indicate that a significant, separately identifiable evaluation and management service was provided on the same day as the preventive medicine service.
Yes, physicians can choose to bill for an office visit instead of office procedures. This may be done to obtain higher reimbursement.
