Procedures – An Example Visit

Aug 5, 2018


Procedures – An Example Visit

Posted in : Physician Groups on by : some jerk

In healthcare today, there are a litany of terms and methods used to obscure interpretation of facts.

For a visit to your local pediatrician where you are an established patient, you may expect to pay a $20 or $50 copay.  In other circumstances, you may owe a co-insurance amount of 20% of any procedures performed.

What exactly is a procedure?  In official terms, a procedure is one of many procedures from a comprehensive list of procedures published by the CMS.

The CMS is responsible for reviewing the list of procedures and assigning relative value to those individual activities that may be performed by a physician in a medical setting.

For argument’s sake, let’s say that I have a mole on my arm that I have noticed changing over the past few months.  I decide to make an appointment at the dermatologist that was referred to me by my pediatrician.

On that appointment’s day, I enter the office and ultimately see the doctor.  His first move will not be to look at the area of concern.  He will evaluate as much as possible.  This is a billing event that is called the office consultation or office visit.  If nothing else happens, you’re now on the hook for just this item.  Next, let’s say that he agrees that the mole that concerned me is bad.  He cuts it off.  That is another procedure.  He furrows his brow and says, “This one doesn’t look good, we should send it out.”

“Oh?” you say.  He doesn’t exactly give you a great deal of detail on this.  The send out is the external biopsy procedure where imaging is performed on the excised tissue to test for things like cancer.  That is a billable event.

He then proclaims, “Let’s take this one off too.”  So he lops it off and looks pleased with himself.  This one doesn’t need to go out, he says half aloud.

Now, let’s recap procedures:

  1. Office visit / consultation
  2. Mole #1 removed
  3. Mole #1 sent to dermatopathologist
  4. Mole #1 at dermpath from step 3 decides to order a stain to enhance the imaging.  You have no control over this.  This is a billable event.
  5. Mole #2 was a clean cut.

You will never have known that the biopsy from step 3 turns into a stain in step 4.  They will simply bill your insurance based on the forms you signed during your visit.  There are now at least 4 but as much as 5 billable events or CPT procedure codes that you will be obligated to pay for.

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