Billing

Virtually every doctor who accepts health insurance uses codes (called CPT codes) that are assigned to every task they and their staff performs. Everything from a simple blood draw, to immunizations, to the ear check, to specimen handling — all these things are “coded” separately.

We use these standard billing codes to tell your insurance company what we have done at a visit. We also submit charges associated with various codes. The insurance company adjusts the portions that they cover and what they expect you to pay as well as what they expect us to write off based on contracts.

Any bill you receive from us is sent after the insurance adjustments have been made and reflect what your insurance company expects you to pay.

The codes we use are to communicate with the the patient’s health insurance company to determine the payment amount that the doctor will receive for his or her services. Each diagnosis, procedure, survey, vaccine, and other service is assigned a code.

The medical office does not choose their own codes. They are standardized among all medical clinics. 

The health insurance company wants to see what was done during a patient’s appointment. Hence, everything the doctor and the staff does has a code. If we fail to code for each issue addressed or every task completed we risk failing to meet metrics set by regulatory boards. This is why we can't simply do a procedure and not bill for it.

For example, if you are coming in for a child’s well visit, the pediatrician will submit a "claim" to the insurance company using the following codes:

• Established Well Visit – 99392
• Developmental Testing – 96110
• Hemoglobin – 85018
• Finger stick – 36416
• Lead Testing – 83655
• Hearing Screen – 92587

If the child gets immunizations, those have codes too:

• Flu – 90660
• MMR - 90707

Vaccine administration also uses a distinct set of codes. To further complicate things, some vaccines have a single administration code used with them, and others have multiple administration codes for a single vaccine.

• Admin – 90460
• Admin – 90461

What happens when something is identified during a well visit that isn't a "well" issue, such as an ear infection? Or what if you ask us to treat the wart or refer to physical therapy for that knee that's been an issue for months?

This question requires the the physician or nurse practitioner to perform an entirely different assessment than the well visit the child was getting.

In order to show the insurance company that a completely different assessment was done, codes are used for those diagnoses and a "sick" visit code is added to the "well visit" code.

Parents often think when they are looking at the bill that the doctor is nickel-and-diming parents, when in reality, it is the insurance company that requires us to show their work in this matter.

The insurance company decides what portion they will pay and what is reasonable but they will have the family pay.

It is the same as going to the restaurant and getting billed for all the side and extra orders. Although the main meal is accompanied by other things, like french fries or a salad, refills, side orders, substitutions and additions to the order are billed as extra. Only it's tricky because no one knows if the insurance company will pay for the sides or if they will require a family to pay for it. 

Why do patients have balances if insurance ought to have paid?

The insurance policy may not pay for all the services performed. So when the billing staff submits a claim for a visit, the health insurance company often comes back and says, "We are not responsible for these codes/services; these are the member's responsibility per the member's health insurance policy.”

For example, the health insurance company may say, the policy your patient chose pays for a vision screen, but not for a hearing screen. Or they may say, we cover the well visit code, but not the ADHD code at the same time as the wellness visit.

We often hear from parents who call to say that they talked to their insurance about a charge and were told that we used the wrong code.

Typically this means that we did a service or ordered labs with a code that is not covered. The insurance complany typically leaves it that we used the wrong code, but rarely offers up which code they will cover.

We can try to change the code to something else that the insurance company might cover, but unless they say which code we should use, it can be a futile game of trial and error.

For example, if we order labs for an obese child to make sure they aren't at increased risk because of high cholesterol, fatty liver, or diabetes, we use a diagnosis code for obesity to explain why the labs are necessary.

If the lab fee is denied by insurance, the parent will get a bill from the laboratory used. (This isn't even Pediatric Partner's bill, since we did not do the lab, but if we pick the right code, maybe insurance will pay for the laboratory fee that is certainly recommended for health risks.) We must change the code so and notify the laboratory so they can resubmit it to the insurance and hope for payment.

We might try any of the following if they apply:

•  E66 for obesity (from experience, this is not paid, so we don't use it)
• Z68.54 BMI, pediatric, greater than or equal to 95th percentile for age (typically what we use on the initial lab order)
• L83 if a patient has Acanthosis nigricans (a skin darkening on skin folds of the neck, often associated with obesity)

If labs were abnormal, we could add the abnormal code, such as "elevated liver enzymes" or "hypercholesterolemia". We can't use these codes initially if it's only a screening because we won't know if we don't test.

Sometimes we resubmit different codes several times before finding the "right" one. (Note, the right one changes from insurance company to insurance company and even year to year within a company.)

One option to avoid getting a bill for extra things covered at well visits is to have you come back later.

If we ONLY do well visit things at the well visit, it is more likely (though not guaranteed) that you will not get a bill. Most of the things recommended in Bright Futures are covered by insurance. 

The "sick" visit issues are never part of a well visit. These might include ear infections, warts, and medication refills for asthma or ADHD. To correctly address and document these, we need to enter it into our charts, which generates codes. Sick visits typically incur a co pay, unlike well visits. So you might have a co pay for the visit added, whether your appointment was scheduled as a sick visit or a well visit, if sick topics are addressed. 

So we can make it convenient and treat that ear infection we see, or refill your child's medications on the day of your well visit. Or we can ask that you reschedule for another day to address the non-well things.

Sometimes the line is very fuzzy. 

Part of a well visit includes depression screens for adolescents. If it identifies depression, it would be poor care to push that to another day. But discussing depression is not a quick add on to a well visit. It deserves time. We deserve to be paid for our time.

By treating additional questions during a wellness visit, the doctor runs the risk of not being paid despite doing the work. On the other hand, not addressing the issues, the doctor runs the risk of upsetting the parent, who will probably think the doc is trying to squeeze another $30 copayment; which is clearly not the case.

One of the major problem with this is that patients don’t understand what they are financially responsible for. Sadly we as medical professionals often don't know either - there are too many companies that are not transparent in their process.

Just like with anything else, you get what you pay for. But patients overlook this issue when purchasing health insurance. They only look at the monthly premiums and chose the lowest one. But by doing that, they are often reducing the amount of coverage, which means patients will get stuck with larger portions of their medical bills.

The health insurance companies, in an effort to keep their premiums low, have shifted the cost to customers and their doctors. While in the past health insurance company’s may have covered 100%, now they are reducing the monthly premiums but only covering 70% of one’s medical expense. Hence all high deductible plans out there.

There are virtually thousands and thousands of different health plans. We even have patients whose parents work for the same company, but have different insurance plan details with the same appearing insurance card.

We don’t have enough manpower or time to sit on the phone verifying every single patient’s healthcare coverage - especially for the additional things added in during a visit. We cannot know that your child will need a breathing treatment when you schedule to be seen for a cough or that your well visit will identify an ear infection in your baby or depression in your teen.

As a practice we believe it is the patient's responsibility to find out what is covered and what is not covered. The more time we spend on the phone with a patient's insurance company, the less time we are able to spend providing health care for our patients. We recognize the futility of this though. We know that you will not get the answers you need from your insurance company - even HR managers struggle to get real answers - and they have connections!

As a practice, we consider that treating patients based on what the insurance covers and what it doesn't, instead of treating by what the patient actually needs, is an unethical way to practice medicine.

Although most doctors will take into consideration health insurance stipulations, they will not compromise a child’s health as a result of health insurance restriction and cheap health insurance coverage plans.

If you have remaining questions, or don’t understand your medical bills, feel free to call our billing office.

The medical industry is different from most because we do not bill our customers directly. We contract with insurance companies, who pay us what they feel is the amount due for certain services. They also have contracts with their policy holders, which describe the payment responsibility for the patient. We cannot alter the contract between a patient and their insurance company. In fact, we do not know what the specifics are between a policy holder and their insurance company. Each contract is different, even with the same insurance company. For example, Blue Cross Blue Shield (BCBS) policies with different companies and with individual plans are different from other BCBS policies, even if they are both PPO or HMOs. There are hundreds of various BCBS policies and each covers different services at various levels. We cannot know what is covered, what is considered not covered at all, or what is considered patient responsibility until we receive payment for services from the company.

We have attempted to discuss our policies on our website so that all patient families can know what our policies are, but we cannot list all covered or non-covered benefits because that is dependent on the contract between you and your insurance company. Please read your policies and ask questions to your insurance company before visiting the doctor so you know your financial responsibility.

We follow strict coding rules and cannot upcode or downcode without breaking the law. This means that a provider should use codes assigned to various sick and well diagnoses and level of difficulty of a visit. Our electronic medical record helps to properly assign codes to visits, which is one reason there is a push by the government to get more physicians on electronic medical records.

One major issue we are seeing is that insurance companies are not all covering separate issues when seen on the same date of service. Pediatric Partners follows the use of CPT as published by the American Medical Association. These CPT codes allow for the use of what is called Modifier -25 to identify separate preventive medicine service (well child exam) and a problem-oriented service (ear infection, hurt foot, earwax removal, etc) on the same date of service.

CPT is very clear on this point. In the guidelines preceding the Preventive Medicine Services codes, CPT states:

“If an abnormality/ies is encountered or a pre-existing problem is addressed in the process of performing this preventive medicine evaluation and management service, and if the problem/abnormality is significant enough to require additional work to perform the key components of a problem-oriented E/M service, then the appropriate office/outpatient code 99201-99215 should also be reported. Modifier -25 should be added to the office/outpatient code to indicate that a significant, separately identifiable evaluation and management service was provided by the same physician on the same day as the preventive medicine service. The appropriate preventive medicine service is additionally reported."

Some insurance companies argue that if they were to follow these CPT guidelines, physicians would game the system and would more often than not find a medical problem that would enable them to bill for both services, so they simply do not follow the guidelines at times.

We argue that our primary motivation in this situation is to avoid inconveniencing patients who present with acute problems at a preventive care visit. Rather than asking them to return on another date to divide the services, we perform both and submit a claim for both. We realize that this might take a few extra unscheduled minutes of our time, which can affect our office flow, but feel that it overall benefits families because a little longer wait time to avoid coming for multiple visits is preferable to most. Insurance companies handle this situation of addressing multiple issues on the same date differently. If payment for the second service is denied, we write it off, since physicians are usually prohibited under contract from balance billing the patient. If the insurance company says the payment is patient responsibility, it is insurance fraud for us to write off this charge. Many families are upset with us when we do not write things off for them, but we simply cannot by law.

A new twist in the use of the Modifier -25 is that insurance companies are putting this cost to the consumer, which is what leads to many billing questions. The extra cost often includes a second co-pay on the same day of service, since multiple issues were covered on that date. Please understand that it is your insurance contract that requires you to pay this portion, not our office specifically. Again, it would be insurance fraud for us to write off this portion of the charge, so we will not.

Unfortunately, because of your insurer's payment policy, in some cases we may have to complete your wellness care and your illness care in two separate visits to allow appropriate billing. If you have a health problem you want to discuss with your doctor during your well visit, the doctor may decide to treat that problem and ask you to schedule another appointment for your well visit. If the additional concerns are not urgent, you will be asked to schedule a separate visit to have that problem addressed.

Please understand that we will work with you to the extent that our contracts allow, but we are also a business and in these tough economic times we must be able to cover our increasing costs. Our rent increases yearly, our office staff and nurses salaries increase yearly. Vaccine costs are outpacing reimbursement rates. Malpractice costs are climbing. Costs to buy and maintain our electronic medical record and website to best serve our patients are substantial — a major reason that few physician offices have electronic medical records.

We would like to provide the best care to our patients in a timely and economical manner, but because of many issues, we may have to have you return for separate visits for each separate issue. We hope that this improves patient care, waiting times, and family understanding of billing practices.