Can I question this office visit bill?

December 7, 2023 9:11 AM

I’ve been billed for a longer office visit than what I experienced, at a new urgent care center.

The new urgent care is a block from my home, so I walked over a couple of weeks ago to be checked out; I was dealing with a week of low grade fevers, a dry cough, and increased asthma symptoms. (In the past, illnesses like this would sometimes turn into bronchitis or pneumonia, so I wanted to rule that out).

There was no one else in the urgent care waiting room. I saw the doctor for approximately 15 minutes. He listened to my lungs and diagnosed me with a bad cold and told me to take Robitussin. No flu test, no other diagnostics. I received the Explanation of Benefits today:

Total cost of service: $431
Insurance member savings: $136.85
Medical plan paid: $0
My responsibility: $294.15

The procedure was billed as 99205, Office O/P New Hi 60 Min

I also paid a $30 copay at the time of visit, which I don’t see listed anywhere. This clinic turned out to be out of network, which I didn’t realize, but the 60 minute office visit is what’s throwing me off.

I’m finding this description online for what code 99205 involves:

Typically 60 minutes
Comprehensive history
Comprehensive examination
High complexity medical decision-making
(Based on high-complexity medical decision-making)

Extensive number of diagnosis or management options;
Extensive amount and /or complexity of data to be reviewed;
High risk of significant complications, morbidity and/or mortality

This doesn’t fit my short appointment. Can I call billing and fight this? Or because I’m a new patient does the 60 mins automatically apply? I know it’s not a huge amount of money but I’d love to pay less.

posted by sucre to Health & Fitness (7 answers total)

Best answer: I also paid a $30 copay at the time of visit, which I don’t see listed anywhere.

I can't speak to the 60 minutes beyond pointing out that "typically" doesn't mean "always", but do want to mention that your EOB probably has a notation somewhere that it's not a bill. Have you received an actual bill from the clinic? That's where I would expect to the $30 reflected. The EOB is a good pointer to what you'll pay but strictly speaking is not going to show what you owe now.
posted by Nonsteroidal Anti-Inflammatory Drug at 9:24 AM on December 7, 2023 [3 favorites]

Best answer: Sure, why not? Worst that can happen is no worse than where you currently are (on the hook for $300 less copay).

Even if they do respond that “this is the standard code for a new patient visit regardless of how long it is” you can certainly push back on that as well. (This certainly doesn’t sound like a “hi” level or “high-complexity” diagnosis). Oftentimes a billing office will be quick to tweak things to resolve an issue, if you approach them politely and aren’t aggressive or abusive about it.
posted by sesquipedalia at 9:45 AM on December 7, 2023

Best answer: Yeah, just call the office of the Urgent Care and act inquisitive: "I got a bill from you that is coded as a 60-minute initial visit, but that doesn't match the actual visit. It also doesn't seem to reflect the $30 co-pay that I made at the office. Can you help me with this?"
posted by hydra77 at 9:50 AM on December 7, 2023 [2 favorites]

Best answer: There are 5 standard CPT codes for Office/Outpatient New Patient Evaluation and Management, ranging from 99201 though 99205 with increasing complexity. I'm not a certified coder, but your description of the visit definitely sounds like a level 2 ("expanded problem-focused" history and exam with "straightforward" medical decision making) or level 3 ("detailed" history and exam with "low complexity" medical decision making) visit rather than a level 5 visit.

Not saying it's what your urgent care did here, but "upcoding" is a known strategy to intentionally overstate the intensity of office/outpatient E&M visits to increase billed charges and revenue. Definitely worth calling their office and politely inquiring if a lower-level code might be more appropriate.
posted by bassooner at 11:18 AM on December 7, 2023 [7 favorites]

Best answer: What you've put up is the medical decision making form of billing, which is on its way out for time based billing. That's said, it does indeed sound like an upbill -- but at the same time, the real number of minutes isn't just the 15 you saw them for.

Time based billing includes all time spent on your care on day of service. I routinely bill for more than the time I see patients because I have to review MRI images myself and, for example, this week, talk to one of the other subspecialists specifically about a case.

But! It doesn't sound like that's something done in your case unless the urgent care has access to like, your old xrays. I'd challenge it.
posted by cobaltnine at 11:29 AM on December 7, 2023 [1 favorite]

Best answer: I am not a certified coder yet but I am studying! E&M (evaluation and management) visit coding isn't just the time spent - it's "level of medical decision making". Always worth questioning charges you don't understand because people/computers make mistakes. Also, if you were not notified the center was out-of-network, you should push back against paying any additional balance - is $30 your in-network copay? Their collecting that would be evidence in your favor.

You say you received an EOB - wait to receive a statement from the center to push back from that angle. They might be not charge you for the balance.
posted by ThePinkSuperhero at 11:56 AM on December 7, 2023

Response by poster: Thanks everyone! I called the clinic, and a doctor called me back (not the one I saw) and said my provider made a mistake with the billing code, that what he billed was “very unusual”, and it would be rectified. I’ll let my health insurance provider know this as well. Glad I noticed and grateful for your guidance here!
posted by sucre at 2:35 PM on December 7, 2023 [8 favorites]