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%?
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