Patient Education 101

Foreword / Introduction

In order to lend credibility to my opinions and advice, I need to introduce myself and give a brief history of why I feel qualified to discuss and advise a patient of things they don't know — but should. I have worked in the medical field since 1998. I began my career as administrative support to a department director for one of the largest hospitals in Knoxville. I assisted the director in all reporting and managed budgeting and purchasing of supplies. From there, I moved into a large specialty practice where I worked 3 months as a Scheduling Coordinator. I advanced to administrative assistant at my 90 day evaluation, and within one year, I added network administrator to my growing job description. At the beginning of 2005, I also added medical biller to my belt — preparing and entering cpt charges for Medicare, Blue Cross, and about 45 other major insurance companies. I was good at my job but left the field in February of this year due to stress-related physical illness and health decline. My purpose and goal in talking to you is a simple one. I'm a working American trying to pursue life, liberty and any happiness I can find. My money is hard earned and the lessons I've learned have all usually been more costly because I didn't have the education I needed to deal with the situation whatever it might have been. And I hope that by sharing these articles, that you — the reader — will take a clearer understanding with you next time you go visit your doctor or hospital for I believe that education is knowledge and knowledge is power.

Lesson One: Understanding Your Bill — CPT Codes Explained

"CPT" stands for "Current Procedural Terminology" and is the national standard that all physicians must use to bill for medical visits. The American Medical Association publishes official CPT guidelines annually and your physician must bill according to these guides. All visits are defined by a numerical code. The codes I refer to are used to report all services provided in the physician's office or in an outpatient or other ambulatory facility. All information in my article here is quoted from: CPT 2005 Professional Edition, The American Medical Association, AMA Press, 515 N. State Street, Chicago, IL 60610.

As you leave your visit with your physician, you should be provided a copy of the encounter form for that visit. This is the form with all the check boxes where your physician or nurse practitioner checks the level of service that was provided to you and lists any other tests or procedures that are to be billed for. The following codes must always have one of these checked:

New Patient Visits

99201 Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: a problem focused history; a problem focuses examination; and straightforward medical decision making. Physicians typically spend 10 minutes face-to-face with the patient and/or family

99202 Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: an expanded problem focused history; an expanded problem focused examination; and straightforward medical decision making. Physicians typically spend 20 minutes face-to-face time with the patient and/or family

99203 Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: a detailed history; a detailed examination; and a medical decision making of low complexity. Physicians typically spend 30 minutes face-to-face time with the patient and/or family

99204 Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: a comprehensive history; a comprehensive examination; and a medical decision making of moderate complexity. Physicians typically spend 45 minutes face-to-face time with the patient and/or family

99205 Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: a comprehensive history; a comprehensive examination; and a medical decision making of high complexity. Physicians typically spend 60 minutes face-to-face time with the patient and/or family

Established Patient Visits

99211 Office or other outpatient visit for the evaluation and management of an established patient that may not require the presence of a physician. Usually, the presenting problem(s) are minimal. Typically, 5 minutes are spent performing or supervising these services.

99212 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a problem focused history; a problem focused examination; and straightforward medical decision making. Physicians typically spend 10 minutes face-to-face time with the patient and/or family

99213 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: an expanded problem focused history; an expanded problem focused examination; and a medical decision making of low complexity. Physicians typically spend 15 minutes face-to-face time with the patient and/or family

99214 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a detailed history; a detailed examination; and a medical decision making of moderate complexity. Physicians typically spend 25 minutes face-to-face time with the patient and/or family

99215 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a comprehensive history; a comprehensive examination; and a medical decision making of high complexity. Physicians typically spend 40 minutes face-to-face time with the patient and/or family

Now, the point I would like to make today is that you should pay attention to the amount of time you spend face-to-face with your physician. It should be within the guidelines above. I would certainly question any charges that seem inappropriate. As of February of this year, Medicare was the first insurance provider who has begun to question only the 99215 charges. At the beginning of 2006, Medicare began requiring all physicians to accurately document 99215 charges in their office notes. Medicare will now review these notes to make sure that the physician actually performed all of the services you are being charged for. It is my hope that other providers will follow this example. If you have a questionable charge, telephone your insurance provider directly and they can assist you in investigating the claim. My next article will address additional charges for services during an office visit.