Doctor's Office Visits

Doctor's office billing is straight forward for the most part if you have insurance or no insurance at all. There are guidelines set forth that doctor's have to follow in order to charge patients based on the time that is spent with them. Below is a quick guide to help you, if it isnt your first visit to the doctor, to  determine if you feel as though you are being overcharged for your visit:

99211 - this is the minimal level that is ordinarily charged when you simply see the nurse or have lab tests performed. Although there are documentation requirements for this level, the minimum time that is required to be spent with the patient is 5 minutes.

99212 - when charged this level, the complaint is self limited or minor and the treatment is straightforward. Physicians are required to spend 10 minutes face to face with patient or family

99213 - Low to moderate severity of a complaint defines this charge, often lab work or xray is performed. Physicians required to spend 15 minutes with patient or family.

99214 - This is a more advanced level, when the complaint is moderate to high, requiring labs, xray and more detailed examination. The required time spent is 25 minutes.

99215 - The highest of all levels in the doctor's office requires comprehensive time spent with the patient/family of 40 minutes. In addition, the complaint is high, such as chest pain.

If it's your first time at the doctor's office, the charges will be higher since you are new to them but the codes parallel the ones listed above.

Where the additional out of pocket costs come for patients is the additional charges. If stopping smoking or drinking is addressed, you will be charged and most insurance companies will NOT pay.

Another trick is when a patient is in for a routine physical and the patient mentions a medical complaint such as headache, etc. The office will not only charge a routine physical code but a code listed above to cover the headache complaint. Let's hope that the coder assigns the correct diagnosis code to each visit as well as the appropriate modifier or else the patient will receive a bill for both.

Anytime a procedure is scheduled, whether its in the primary physician's office or at a specialist's office, some insurance companies require pre-authorization. If this isnt obtained by your doctor, you will be responsible for the bill. Always get a copy of the pre-authorization including a reference number!!

**Self pay patients -  ask for the insurance discount instead of paying the entire bill. Most insurance companies pay at 80%, requiring the doctor's office to absorb the additional 20%. Why should you be required to pay 100%?

Doctor's Office Visits & Medicare

If you are a Medicare patient, there are certain tests that Medicare will not cover and the doctor's office is required to notify you of this in writing BEFORE the test is performed. This form is called an ABN - advanced beneficiary notice. If you are not notified before the test is performed and Medicare denies payment as a non-covered service, you may NOT have to pay for it.

Below is the link that Centers for Medicare and Medicaid Services that provides a detailed explanation of the use of an ABN:

https://www.cms.gov/MLNProducts/downloads/ABN_Booklet_ICN006266.pdf

Most lab tests are sent to an off site lab instead of being processed at the actual doctor's office, which means that the patient will probably receive an additional bill.

Another little known fact or benefit used by Medicare patients, is the free "Welcome to Medicare" preventative physical which must be used within the first 12 months of being on Medicare.
No deductible or copay is charged by Medicare if the visit is coded/billed correctly.  The correct procedure code that must be submitted in order for the visit to be paid is G0348.

However, in addition to the wellness exam, physician's routinely will charge an additional code if any health problems or concerns are addressed. This is when your co-pay and deductible will be applied.

Other ways physician's charge separately include anytime they address stopping smoking or drinking. There are procedure codes that will be billed in addition to the office visit, which in turn will cause more out of pocket costs for Medicare patients.

One code that is routinely used incorrectly for Medicare patients is 99211, which is defined:

“Office or other outpatient visits for the evaluation and management of an established patient, that may not require the presence of a physician. Usually, the presenting problem(s) are minimal. Typically, 5 minutes are spent performing or supervising these services.”
Among other things, code 99211 should not be used to bill Medicare:

• For phone calls to patients.

• Solely for the writing of prescriptions (new or refill) when no other E/M is necessary or performed.

• For blood pressure checks when the information obtained does not lead to management of a
condition or illness.

• When drawing blood for laboratory analysis or when performing other diagnostic tests, whether or not a claim for the venipuncture or other diagnostic study test is submitted separately.

• Routinely when administering medications, whether or not an injection (or infusion) code is submitted on the claim separately.

• For performing diagnostic or therapeutic procedures (especially when the procedure is otherwise usually not covered/not reimbursed or payment is bundled with payment for another service), whether or not the procedure code is submitted on the claim separately.


Anytime there is a question about a charge that you feel is unfair or unsubstantiated, please call Medicare to voice your concerns.

Patient Advocate

I have worked in the medical billing field for over 15 years experiencing many different practices and have a wealth of knowledge for PATIENTS on how to understand and possibly even negotiate your medical bill lower.

Its really not as difficult as it sounds to get a lower medical bill. Especially when you understand how the process works. That is the goal for the next post, to explain the process with a couple of different scenarios. One is the physician office setting and secondly in the emergency department setting.
Why am I doing this you may ask? Simple. Over the years I have watched countless numbers of doctors and billing company owners get richer while patients are struggling to pay their bills, some of which aren't correctly coded or the insurance payment isnt calculated right, leaving the patient with more of a balance than what is owed.

This is my new stance on life, to become a patient advocate and help explain the billing process and reveal secrets to help PATIENTS minimize their health care costs.