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Accountant at Work

Billing Questions

Will my office visit be billed as a physical or a problem-focused exam?

Who decides? Why should I care?


     Those are some great questions.  I wish the answers were clearer than they are. Let me start with the last question first.

You care because the way the visit is billed greatly impacts what you owe personally as opposed to what insurance will pay.

Most commercial insurance will pay 100% for an annual preventative exam. You pay very high premiums and have a high deductible, so it seems right to receive that benefit. This would be a good time to encourage you to read your policy or call your insurance to be certain of that coverage.

     Medicare, on the other hand, never pays for a "physical". If your visit is billed as a routine physical, they will pay zero. You pay 100 % of that bill. However, selected Medicare Advantage plans will pay for an annual physical. And every Medicare policy - whether regular Medicare or Medicare Advantage - will pay for an "Annual Wellness Visit" at 100%.

     Are you confused yet? Maybe it will help to explain what these terms mean in regards to what is actually intended during the office visit. Because I now answer the second question of who decides how the visit is billed.

     Criteria considered in assigning the proper billing code are two:  1. What was the main purpose for the visit?  and 2. What was accomplished at the visit?  And the responsibility for assigning that code lies with the Provider who performed the visit. As Providers, we have both ethical and legal mandates to do this correctly.

     A problem focused exam is what it sounds like. The patient presents with a specific concern(s) or problem, such as chest, abdominal, joint or other pain process, a bad cough or shortness of breath, unintended weight loss, etc - and the provider's focus is on that issue. It also occurs when the patient presents for a follow up of an established problem such as high blood pressure or diabetes.

     A "physical" or "annual health exam" is a more general focus on both established medical and preventative issues. The providers take a broader focus of overall health maintenance. This also occurs when a patient is establishing care with a provider. It is a scheduled visit once yearly.

     An "Annual Wellness Visit" is limited to Medicare patients and is restricted entirely to preventative medicine including vaccinations, covered diagnostic exams, assessment of safety and function, assurance of medication list accuracy, end of life decision making, etc. These visits are extremely helpful, they are paid at 100%, and Evergreen encourages every Medicare patient to take advantage of this benefit.

     The truth is that sometimes these visits fall in-between problem focused and annual exam criteria and could be properly billed either way.  When that occurs, we will do our best to work with our patients and their insurance policy to allow coverage. We will not misrepresent the office encounter, but we do want to reduce the cost barrier to medical care wherever possible.

     We appreciate your patience and understanding of the complexity and murkiness that sometimes accompanies these decisions. Our first priority is to take care of you and your family whatever your need.  Please let us know if you believe we have not billed your insurance in a correct fashion. We may or may not be able to correct that, but we can always explain our reasoning.



      Your friends at Evergreen Family Medicine.

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