Appointment Types & Cost Estimates
There are four main types of appointments:
1. WELLNESS PHYSICAL
2. OFFICE VISIT
3. CASH APPOINTMENTS NOT MEDIATED BY INSURANCE COMPANIES
It’s not our decision. Appointment types are defined by the American Medical Association and health insurers like Medicare and private companies. This matters to you because each appointment type has a unique “CPT code” and each CPT code translates to a fee you will be charged for your visit. That fee, called the “allowable fee”, is different for each insurance company. The portion of the allowable fee that you will pay out-of-pocket will depend on your “co-pay”, your “co-insurance”, and your “annual deductible” (see http://imwisepatient.com/direct-pay-options/). What is aggravating for patients and most physicians is that the allowable fees for “office visit”, the most common type of appointment, depend on the “level” of the office visit, which is calculated AFTER the appointment has occurred, often by professional coders and/or software. Not knowing what something costs before you buy it (or sell it) is frustrating at best. Want some real life examples transparency problems in healthcare billing? Read this: http://healthland.time.com/2013/02/20/bitter-pill-why-medical-bills-are-killing-us/
Below I describe the most common appointment types and give you their CPT codes in table form. You, in turn, can contact your insurance company to ask what their “allowable fee” is for appointments at Wise Patient for each CPT code. From the allowable fee you can readily calculate your out-of-pocket cost for the different appointment types.
1. Wellness Physical
During this visit type, I review your past medical history, family medical history, health habits, current medications, and allergies. I perform a screening physical exam. I synthesize the information into a personalized assessment of disease risk. I recommend for or against additional screening tests to screen for common cancers, and screening tests to help clarify your risk status for heart attack or stroke. I discuss the impact that lifestyle can have on your particular health future.
What is not included in a preventative screening physical? By CPT coding rules, the preventative screening physical cannot include “active management” of a medical problem or symptom unless a separate “office visit” is also coded alongside the screening physical – which will transform the appointment type into a combined visit (described below). Medication refills and dose changes can be included in the preventative screening physical, but new medications, treatment strategies, and referrals (other than screening referrals) trigger CPT codes for “office visit”.
These distinctions are important because some insurance companies waive all out-of-pocket costs for one preventative screening physical appointment per year (i.e., no copay,no co-insurance, no deductible payment). Be sure to ask your insurer if they are one such company. When you schedule a preventative screening physical – with Wise Patient or any other clinic – you should emphasize to the clinic that you are scheduling a preventative screening physical. That way we can do our part to insure the contents of the visit do not include things that would trigger an “office visit” code to be generated and billed out.
Preventative Screening Physical CPT codes:
|New Patient||Established Patient|
2. Office visit
This is the most common appointment type and is divided into levels 1 through 5 (each with its own CPT code) based on counseling time, medical risk, and decision-making criteria that are so complex and byzantine I still can’t keep them straight. As I mentioned earlier, most clinics use professional coders and/or software to help generate CPT codes for an office visit, which defends the clinic against any claim that it applies charges to different types of patients differently. Believe it or not, “down-coding” an appointment in order to charge a patient less than the calculated office visit level is penalized the same as “up-coding” in order to charge a patient more than the calculated office visit level! The legal word that describes this is “malfeasance” by unfairly favoring some patients over others. Most office visits trigger the CPT code for one of levels 3 through 5, since level 1 can’t even involve the doc and level 2 gets surpassed readily in visits of any substance.
Office Visit CPT codes:
|New Patient||Established Patient|
3. Appointments not mediated by insurance companies
This is the most straightforward appointment type, and the least bureaucratic. The main hassle is that we ask you to sign a paper that says you don’t intend to request reimbursement from a third party such as an insurance agency. That’s a legal thing for us. From there, the breakout is as simple as this:
New Patient, Comprehensive: $200 paid at time of service
New Patient, One Topic: $100 paid at time of service
Established Patient, 30 minute appointment: $150
Established Patient, 15 minute appointment: $100
Annual Preventative Exam, age 50+: $200
Annual Preventative Exam, age under 50: $150