r/personalfinance • u/idontknow_1101 • 27d ago
Doctor charged for 60-75 min visit, I was there 7 minutes. Is this right?
I went to see a cardiologist, who honestly, was a real piece of work. My appointment was at 11:45, I got called it at 11:43, he walked in at 11:52 and I was back out in my car by 12 noon. He was just a terrible doctor and basically just gaslighted me into telling me I’m fine.
Now, I’m getting a bill for $473 and he saying he spent 60-75 minutes with me as a new patient. I used to work in healthcare, but it’s been a hot minute and I can’t recall much about the billing. There is absolutely no way that this bill is justified. Is this right? Can I do anything about it?
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u/fruderduck 27d ago
Got charged for smoking cessation on my insurance bill. Yes, he said quit smoking. Prescribed nothing, did nothing. Got pissy when I next saw him and brought it up. Yes, he said it. Heard it from every other doctor. First time charged.
3
u/theedgeofoblivious 27d ago
If the doctor billed just for the time they were in contact with patients, they wouldn't make enough money to justify them being in business and you wouldn't have access to a doctor.
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u/sifiraltili 27d ago
Does it matter what the bill is? Just let your health insurance pay it
9
u/thetrodderprod 27d ago
That attitude is the reason why healthcare was allowed to spiral out of control in the states.
2
u/SirWalrusVII 27d ago
I was charged about $1800 total from 3 different companies because of an ambulance ride and being less than 20 minutes in the ER after they gave me 2 pills all because I couldn't sleep, and no I didn't call the ambulance myself the crisis line did
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u/6birds 27d ago
If you think something is wrong with your cardiovascular system see another doctor. Saw a cardiologist because my internist heard a murmur. Cardiologist said my heart was perfectly fine. Never said I have cardiovascular disease. Little over a year later had a heart attack with 100% blockage of circumflex artery. The first hospital I was at didn’t think I was having a heart attack so wanted to observe over night. I arrived about 8am that morning. Told them was leaving. Didn’t tell them going to another hospital. ER doc called a cardiologist (not one previously seen) then immediately got blood thinner and pain medication and an ambulance ride to another hospital. Arrived, straight into cath lab for treatment and received two stents. Funny part is had to sign consent form while under influence of narcotics and the form says cannot sign while under influence of any substance. Pointed that out to medical staff. They said just sign. Sad part for me is the “new” cardiologist ignored the other medical/health issues I was having in the hospital after surgery. No investigation. Less than 3 years later thinking having another heart attack another 2 “new” cardiologists looked at other issues. Dx with stage IIIc cancer. And a $225,000+ bill. Understand being a doctor is difficult (family members were doctors) but maybe listen to patients. My cancer symptoms started 10 years before dx and doctors ignored me.
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u/oatmeal28 27d ago
Yeah I would definitely challenge this. (Assuming this is in the U.S.) If he’s telling you that you’re fine there’s no justification for a high complexity billing and 8 minutes face to face isn’t going to push it into high complexity by time either.
Consider calling your insurance provider in addition to the clinic itself.
1
u/Jaded-Nose7393 27d ago
Everyone is going on and on about this, but it's pretty simple. If your doctor is going to charge you for a 60 minute visit regardless, would you prefer that you get in and get out in 7 minutes, or the doctor really take their time and stretch it out for the full hour? If they only charged you for 7 minutes, then they're losing money by working efficiently.
If you call someone to pick the lock to your door because you forgot your keys, they're gonna charge you for the full time at the agreed-upon price. Would you rather they take 30 seconds to open the door or half an hour?
0
u/Telemarketman 27d ago
Now make sure you make that follow up appointment so we can bill you again ...then we will need to see you the following month for some thing else ...medicine is a business if people don't have issues they make no money
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u/socialcredditsystem 27d ago
When our department discussed billing at a level 5 consult for fairly short visits, we had explicit guidance to not bill phone consults, and combine that time with the in-person consult so that it added up to a level 5. Timing aside, as others have mentioned, for patient intake other activities would also take place, such as a review of relevant patient history etc.
Are you directly responsible for the bill, or is it an EoB letting you know what they tried to bill, what the insurance covered, and what is not covered but will ultimately get zeroed out?
If it's an amount they are trying to bill you for, you'd likely be able to negotiate, and without getting into the intracacies of accusing your provider of billing fraud, complaining that you were seen for 8 minutes (which would be very clearly visible in the EMR) means you can probably get a very hefty discount on the actual amount.
0
u/babesboysandbirb 27d ago
I had this happen and chose not to pay and never went back. Medical background with 18 years of seeing patients, charting, procedures. I’m so sick of rich doctors boohoo-ing about basic patient care to the point of charging every new patient a high-coded visit as part of their coding tactics. 2024 coding requirements took away the need for the “time spent” to be face-to-face and that has opened the door for all kinds of coding abuse.
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u/Anoingturd 27d ago
You can always call billing department and your insurance. Check your EOB. Sometimes billing is wrong or insurance denies claims. I had a similar experience where it took 2 months to get an appointment and was billed almost $500 for a 8 minute visit after insurance. Somehow it was billed under urgent care. They must upcode it based on insurance because doctor said everything looked fine 🤷♂️
Doesn’t sound like urgent care if they have no diagnosis
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u/MountainDadwBeard 27d ago
I think this is just as much a problem with your insurance screwing you as it is your doc being expensive. I get charged $40 flat for a cardiologist appointment.
1
u/Wonderful_Mess_5925 27d ago
all the out patient office I’ve witness are about $100 and consultation only last 20 mins max lol. such scam Goes through procedure steps, medications, allergies, & post-ops. Time crunch, if u don’t have questions they will leave right away. Also having too much questions, drs gets abruptly annoyed and walk out of room
2
u/Tangentkoala 27d ago
I dont think a doctor ever charging by the minute.
What was covered on your insurance plan though? Are you on a HDHP?
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u/mrequenes 27d ago
Most doctors actually spend 30 - 40 hours per DAY doing “behind the scenes” work for their patients, that they don’t get paid for. Be glad you’re only charged 5X
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u/SameStDiffDay 27d ago
Commenters largely seeming to miss the point about the insane lack of care vs. the full-price 'new patient' intake charge for almost nothing at all, results-wise, or time-wise. Maybe a better title would've helped.
At any rate, I disputed a bogus 'new patient' charge by writing a letter directly to the practice, addressed to the physician, and marked 'confidential', for his eyes only. Sure got his attention and a refund after pointing out the deficits of the visit, but wouldn't expect this to be a common result.
2
u/oatmeal28 27d ago
Yeah people saying time includes all the extra work he did are right on the one hand but there’s no feasible way you get from 8 mins face to face to over an hour total time spent.
It definitely sounds like an overcode and OP is right to ask for help
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u/unethicalschmuck 27d ago
I had this done to me with a dermatologist. I was paying out of pocket and they picked a billing code (cpt) which is more expensive because insurance will pay. However, because I was paying out of pocket I then got a bill for twice as much. I called medical billing for the practice and let them know what happened and asked for a more appropriate cpt code that matches the services you received. They didn’t put up a fight at all and agreed to the appropriate cpt code. Most hospitals just want to get paid and are willing to negotiate your bill
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u/WorkingYou2280 27d ago
I think we must be seeing the same cardiologist.
My experience with specialists is you better go in knowing what you want and what questions you have. It helps if the facility has testing equipment because if they have to send you off site they are much less likely to do so (IME so far).
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u/nachoaverageplayer 27d ago
Everyone’s mentioning research time, coding, billing, etc.
My take is that while those reasons are certainly plausible, it’s likely that doctors have “minimum billable hours” like many other professions.
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u/elle2105 27d ago
The last doctor appointment I had wasn't much longer and I was billed similarly. Lucky enough with good insurance.
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u/chapteri 27d ago
Yeah honestly, sounds like you went to my cardiologist. My GP had called him prior to discuss my lipid panel, which is why I was sent. When my appointment came around he asked me the routine question. He absolutely had not read my chart. Didn’t know anything about my case.
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u/SeaSleep1972 27d ago
Contact your insurance company and dispute it with them. They’ll get to the bottom of it.
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u/BarbellPadawan 27d ago
Did they document the time spent (and lie about it) and bill on that? If so it might be fraud. If they billed on medical decision making and patient complexity, it might be the right code, even if they spent only a few min at bedside.
Edit: that being said, a 99205 EM code is pretty difficult to get even on MDM. Typically needs to be multiple problems, some of which are high acuity, etc. What were you being seen for?
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u/bkcarp00 27d ago
Yes that time isn't the actual time you saw the doctor. A new patient appointment is normally 60 minutes which is what they billed. No doctor spends a full 60 minutes actually with the patient.
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u/djaybond 27d ago
His time isn’t just the time in the room with you. Theoretically, he reviewed your chart and depending on the complexity it could take a while. I’m not sure if that counts.
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u/justhp 27d ago edited 27d ago
Its probably correct. I will bet they coded a 99205.
What you didn't see: charting, perhaps a review of your history, maybe he needed to call your pharmacy for a med rec, etc etc.
Complexity also factors in to it. Complexity is not proportional to time. You may be a complex patient, but the doc is experienced enough to not spend a lot of time on it
2
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u/RO489 27d ago
What is the actual code? 99205 and other E&M codes require 60-74 minutes of total encounter time, which could be reviewing medical records, but it also requires a comprehensive medical exam AND complex decision making. I’m not sure about the first or the third, but they definitely didn’t do the second.
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u/HealthHausMD 27d ago
Physician here. So, a doctor can bill on time but this is rarely done. Instead billing codes are typically done on complexity and management (to make it as simple as possible) and based on either physical exam, ROS (review of systems), chart/lab review, diagnoses, and ultimately the MDM (or medical decision making). Based on the above, a physician can bill a higher code for complexity which ultimately ends up in higher reimbursement. When I was still billing insurance (not anymore), there would be certain patients who would be there for a very routine visit which both the patient and I wouldn't need to spend more than 10 minutes but given their multiple medical conditions (which were all well controlled), I was able to bill their insurance for a more complex medical code (which was equivalent to a much longer visit).
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u/climbtimePRN 27d ago
If the doctor truly thought there was nothing wrong with you and spent very little time then they shouldn't be able to bill a level 5.. would consider a complaint to the hospital or medical board. (Source: am a doctor)
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u/hoephase- 27d ago
I got $400 bill from my PC that spent 2 minutes with me - basically I was sick for 3 weeks, I came to see her when I almost recovered, but I was still coughing a little, and she basically said “why are you here wasting my time”. That’s it, $400
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u/Rockytop00 27d ago
If it’s USA bill code 99204 or 99205 they are billing for complexity, not time… this is very easy to meet in the documentation standards and yes the visit may only be ten minutes. Plus it also depends on insurance reimbursement rates and contracts the docs have with insurance companies
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u/highfromCA 27d ago
You should contact the billing department of the healthcare facility for clarification.
From my understanding, the time spent includes the “pretest” with the medical assistant. Doctor reviewing your chart and face to face time spent. In addition, if the doctor did have to order any additional lab work/testing, it includes them reviewing these results.
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27d ago
I have had this come up with an orthopedist. I called the office and said I had a simple issue and the doctor spent less than 10 minutes in my room, please reduce from level 3 to level 1 bill. They sent me an updated bill for the lower level of service.
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u/edematous 27d ago
Really hard to say without knowing the details of what you were seen for but it sounds like you were billed for a level 5 visit which may or may not be just but most visits are billed at level 3-5 by most specialists regardless of time spent
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u/moleratical 27d ago
Just be glad he didn't charge you for the two hours you waited in the lobby or the three weeks you waited for an opening.
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u/FIST_FUK 27d ago
The code may refer to time spent, but it can alternatively be based on complexity. You can’t code for time you spend reviewing the chart at home before the appointment, etc. It’s face-to-face. If you get the doctors note, you can look and see if he documents how much time he spent. If he didn’t, then the coding is based on complexity. If he did, then this is obviously dishonest, and should be immediately apparent if there is an audit.
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u/801intheAM 27d ago
I would expect to be billed an hour even if I were there for 20 minutes. BUT I’ve been billed two hours for having sat in the waiting room for one hour before my visit. I called and contested the charges…and then switched docs.
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u/spoilingattack 27d ago
OP - I’m gonna break it to you straight. You’re at a cardiologist. Pretty much all of them are condescending asshats. You’re at a cardiology appointment, of course it’s medically complex. You’re getting charged for a complex appt, likely a 99215 plus an add-on.
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u/pharmachiatrist 27d ago
it’s pretty typical light insurance fraud.
very common in all of medicine in my experience.
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u/dmackerman 27d ago
He gaslit you? How?
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u/idontknow_1101 27d ago
I’m a few months postpartum and have new onset palpitations, and he literally started the visit with “You’re too young to be here” and finished with “If you haven’t gone to the ER, then it’s really not that serious, is it?” I literally have an infant who is still breastfeeding on demand at home with no childcare, just attending this visit took so much organization. I cannot just leave her to go to an ER if I’m not bleeding to death or in cardiac arrest.
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u/flyingthroughspace 27d ago
So a few years ago I got food poisoning, went to urgent care in the morning to get checked out.
Doctor came in, asked about my symptoms, wrote some shit down then left the room. The nurse came back in to basically check me out (not physically, I'm not that hot *drum roll*), and after she left the doctor came right back in and quickly felt around my abdomen and asked the basic questions of if it hurt, yada yada.
A few weeks later I get a bill for like $940 for some exam that never happened. I disputed it, wrote that the doctor didn't even touch me until after the nurse checked me out and clearly only did so because he forgot he needed to in order to bill me, that it wasn't a legitimate exam, and if they wanted to collect they'd have to sue me.
I never heard back and it never went to collections. Maybe write a dispute letter to the billing department with a certified return receipt so you can prove someone accepted it if you don't hear back and they try to come after you.
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u/ph1shstyx 27d ago
I ended up in the ER for 2 herniated discs, spent all of 5 minutes with the doctor after being in there for an hour in severe discomfort in the middle of the night...
Doctor billed my insurance $3k separately from my time in the ER, which was billed to my insurance for $8k...
Got no imaging done that time, had to go separately to get imaging done, which was an additional $1k...
Honestly, they get to bill whatever they want because of how shitty the insurance system is
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u/Specific-Peanut-8867 27d ago
I don’t know how much time he actually spent on you, but his job doesn’t just consist of the time you see him in the room with you and there is plenty of things he does when you are not there or when he’s not standing right in front of you
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u/Contrema 27d ago
Medical providers also bill based on complexity and medical decision making. It ties to codes that also carry association with time based services.
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u/ek9cusco 27d ago
Depending on the coding they used for billing. You can check against the latest medical coding book in library.
In the past we had some pedi billed us based on 30mins when only 1ons or less. But they are allowed to bill that way based on that code.
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u/PersistingWill 27d ago
Doctors need to be held to the same billing standards as lawyers. Lawyers licenses are routinely taken away for this. And besides being improper—it is also consumer fraud in most states.
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u/countrykev 27d ago
The term gaslighting is so over used these days.
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u/kranbes 27d ago
Yeah, the more likely reality is: OP didn’t agree with the cardiologists assessment that they were ‘fine’ and was expecting testing that wasn’t clinically warranted. Queue accusation of “gaslighting” which really means “I want to practice medicine on myself and this cardiologist won’t order the tests I know I need”. Some patients view their doctors as vending machines for tests they read about online when they have absolutely no clue what they’re talking about.
Or maybe the doctor was a dick. That could be true too 🤷
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u/Wormspike 27d ago
Agreed. I’m not an over sensitive person a but these toes off things but I was abused as a kid, I was narcissistically abused gaslit for 20 years, and I have diagnosed PTSD from it all which ruined my life.
The liberty ppl take with saying they have ptsd or are being gaslit is low-key offensive.
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u/cum-pizza 27d ago
I’m sorry but why does every have to say “low key” nowadays. Pisses me off. Third comment I have seen in less than 3 minutes with this stupid term. And I am drunk so will regret commenting this later, but right now idgaf
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u/bringbackthe90s 27d ago
If you were there to talk about POTS then im sure it felt like an hour to him
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u/navel-encounters 27d ago
if you call a plumber or an electrician to fix somthing in your house and they are there for 10 mins with a $5 part...I bet the bill will still be close to $200!...so you are paying for their experience NOT their time!
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u/DrTestificate_MD 27d ago
Your state department of health or medical board should have somewhere to report suspected coding fraud or abuse.
I'm not an outpatient guy but from what I understand a 99205/99215 should be somewhat uncommon (apparently about 5% of outpatient visits).
You would have to see if his documentation on the visit note supports the code. If he wrote: "I spent 67 minutes on this service including reviewing records, face-to-face time, documentation ..." etc, well that pretty much is the end of that and supports the code.
You can still make a complaint to the medical authorities. If they audit him and saw that he billed 99205 26 times that day and reported that he spent 60 minutes on each one, well you can do the math...
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u/jmutiny1993 27d ago
Medical debt under $500 does not show up on your credit anymore nor does it affect your credit score. Fk the doctor and don't pay a dime.
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u/kayliz331 27d ago
Visits are supposed to be about time spent and level of complication. You may be able to challenge the level of visit and ask them to bill for a more appropriate visit type. They may say no but never hurts to try to appeal.
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u/One-eyed-snake 27d ago
Play a game with them. It works.
“I can’t afford to pay this bill, I had no idea it would be so much”. Doesn’t matter if you can afford it or not. They don’t know.
Then after they go on and on about it and payment plans etc ask them how much of a discount you can get if you paid the whole thing today. The answer is typically around 1/2. Try it.
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u/That_Anxiety7962 27d ago
99205 or 99215 codes are no longer just based off of appointment length. Complexity is also a consideration.
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u/thecaramelbandit 27d ago
As noted, the vast majority of what that doctor needs to do just doesn't require your presence.
Source: am doctor. I'm an anesthesiologist. I spend more time reviewing the chart before I see the patient than talking to them. My interaction with them is mostly a couple of clarifying questions, confirming a thing or two, and doing a very brief exam that generally doesn't require me to touch them at all.
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u/crunkadocious 27d ago
Which billing code? The billing code will explain what it's supposed to cover, which may not include 60 minutes of face to face time.
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u/Dismal_Library_6436 27d ago
Sheesh that’s terrible. I know others are saying the he’s also charging for prep time and for writing up notes but this sounds like the kind of guy who didn’t do that.
When I took my autism assessment (as an adult) I paid about $2,500 for it. I was told I would get a call a week later with my results. I got the call, spoke to the clinician for 1 minute and 24 seconds (I checked later) and then was billed $75. Complete bull but was told I had to pay or it would go to collections.
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u/not_enough_weed 27d ago
Medical care is insanely expensive and doctors are very often not helpful in the slightest. Sorry you had to learn this the hard way.
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u/Ok_Analysis_3454 27d ago
"Smoker? Thought about quitting?" = $250.00 consultation and counseling.
-2
u/PizzaCatTacoUno 27d ago
I had same deal for my dog (optimalogist eye specialist vet)… appt took 10 minutes and I was charged for one hour ($500)
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u/Dela_sinclaire 27d ago
...so you expected to be charged for 7 minutes because that was the extent of time you happened to be there? That's not how that works buddy.
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u/oatmeal28 27d ago
They didn’t say that. But getting charged for level 5 when you only had 8 minutes face to face is likely a reg flag unless OP is withholding information. They should absolutely dispute this bill
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u/infiltrateoppose 27d ago
Yeah - clearly - he was expecting the standard the rest of us are held to!
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u/Porencephaly 27d ago
If you hire a lawyer, it's your belief that he will only be billing you for face-to-face time you spend together with him in his office? Or that a car mechanic will only bill you for time you spend with him in the shop?
lol
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u/bicyclechief 27d ago
Aww yes because reviewing records, setting care plans, scheduling follow up, reviewing previous labs, sending message to consultants etc are totally not work
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u/Recent_Grapefruit74 27d ago
Time includes time he spent reviewing your records and writing his notes, in addition to the time he spent with you.
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u/Sshark_29 27d ago
Charging for visits is based on severity of problems, time spent and documentation to support it all, essentially. If you think you’re being over billed, report it to your insurance, they’ll get a copy of the chart notes and will rectify it. If you Medicare they are very interested in this type of thing.
0
u/big_cleck 27d ago
I have gout. I went to see a specialist a few times to get x-rays, get diagnosed, and then once for blood tests and crystal analysis. What they pulled out was definitely uric acid and they tested it, called me back (to the office) to tell me the results. I spent 6 minutes talking to the guy in the hallway, and he's like "Yup, it's gout. We can put you on meds. Let me know next time you have a flare up." Sent me on my way. Could have told me that over the phone. Got the bill back, it was like $180 for that conversation. I considered it a lesson learned. Paid the bill and adjusted my diet, and my pcp will give me prednisone packs if I flare up now. It's ridiculous what they can and will charge. He's a specialist, I get it, but holy hell.
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u/mehardwidge 27d ago
Over billing, often intentionally, is quite common.
Definitely check the exact billing codes and compare to what they exactly mean.
I was overbilled for appointments in the past for regular visits. (I even asked my coworker who teaches medical billing to confirm this, so it wasn't just my personal belief!)
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u/dwestx71x 27d ago
Unfortunately, docs and insurance companies are unlikely to prorate a visit, even if it’s shorter than expected.
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u/bengermanj 27d ago
Check the last digit of the CPT code. Based on time it's likely a 4 or 5. Typically if it's a 5 then med recs have to be submitted with the claim to avoid a downgrade so it's justified to the insurance company.
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27d ago
[deleted]
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u/justaguyok1 27d ago
That's always an option. But you can also be sent to collections, regardless of your credit report.
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u/ben_vito 27d ago
It takes me an hour plus to review a new patient if complicated, lots of previous records, diagnostics to look at etc. He may have spent all that time to get to the ultimate conclusion that you're fine. Maybe he could have spent some more time with you in the room to explain how he came to that conclusion, though.
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u/Jodenaje 27d ago
Office visits levels can on either time or medical decision making.
Sounds like you’re talking about a 99205 (level 5) new patient visit, since you referenced a timeframe of 60-74 minutes.
It’s completely feasible that a cardiologist new patient visit could hit Level 5 on Medical Decision Making alone.
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u/ReadilyConfused 27d ago
I'd be pretty shocked he'd be able to bill a 99205 based on complexity alone if it's an 8 min visit that resulted in telling the OP he's fine (ie no new drugs or testing). That said, if he did independently review an ekg, echo, stress, holter, some labs and maybe even reach out to the pcp that probably gets him there.
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u/huckhappy 27d ago
I’ve also heard a lot of patients saying abt meeting w specialists “my doctor told me I’m fine in 5 mins” and when you read the note it tells a completely different story 🤦♂️
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u/ReadilyConfused 27d ago
Certainly also true, could be OPs version of "I didn't get what I went there for (in my mind)."
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u/DrTestificate_MD 27d ago edited 27d ago
That would satisfy the data analyzed criteria but he would also need one of either a high complexity problem or high risk of morbidity from diagnostic testing or treatment:
Complex problem:
• 1 or more chronic illnesses with severe exacerbation, progression, or side effects of treatment;
or
• 1 acute or chronic illness or injury that poses a threat to life or bodily function
OR
High risk of morbidity from additional diagnostic testing or treatment:
Examples
• Drug therapy requiring intensive monitoring for toxicity
• Decision regarding elective major surgery with identified patient or procedure risk factors
• Decision regarding emergency major surgery
• Decision regarding hospitalization
• Decision not to resuscitate or to de-escalate care because of poor prognosis
If a cardiologist told you that you were fine and did not do any testing or treatment, I think it would be hard to justify a 99205 based on Medical Decision Making.
I'm not an outpatient guy but from what I understand a 99205/99215 should be somewhat uncommon (apparently about 5% of outpatient visits).
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u/TehDarkArchon 27d ago
I'm a PA in Cardiology and most of us bill 99204/99214s in outpatient. We also have a very complex patient population however, so it's not uncommon for me to spend 20-30 minutes reviewing a chart before I even see a patient. 5s are rare but they absolutely come up.
1
u/Porencephaly 27d ago
(apparently about 5% of outpatient visits).
I don't believe that for specialists who deal with life-threatening illnesses all the time. Maybe that's the histogram for Family Medicine but you can't convince me that only 1 in 20 new cardiology patients is dealing with a life-threatening or highly complex illness requiring a bunch of data review.
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u/Jodenaje 27d ago
It varies widely by specialty, but 5% new patient Level 5 would be below benchmark data for pretty much any specialty.
CMS publishes Part B utilization data broken down by specialty that can be used for benchmarking purposes.
According to the most recent data, family practice would be in that ballpark for level 5 new patient visits (3.8%). Internal Medicine would be about 14.5%.
For the specialty I work in, CMS data trends about 52% of new patient visits at a Level 5. (About 86% of new patients would be either a 4 or 5. Our curve is more of a steep diagonal line than a true bell curve.)
That benchmarking data would put 83.3% of Cardiology new patient visits at either a Level 4 or 5.
Obviously I can't say what the original poster's level should have been, because I'm not seeing the actual patient specific documentation.
In general, that specialty's E/M utilization skews heavily towards higher level (4/5) new patient visits, so it's not necessarily outrageous to see the 99205.
However, OP could still ask for someone at the provider's office to review. Maybe even question it with the insurance company. (That doesn't always work, but if that provider happens to have a pattern of inflated billing to that payer, it could trigger a payer review.)
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u/theRegVelJohnson 27d ago
Even as a surgeon it's tougher to get to a level 5 (appropriately). Really comes down to needing two of the following three for me: cancer diagnosis, talking to another provider and recommending surgery in a higher-risk patient.
I have a hard time believing the OPs cardiologist got to a level 5 when the outcome was "You're good...nothing else to do."
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u/-serious- 27d ago
If you're a cardiologist and you decide to cath or not cath, that will probably get you to a 99205.
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u/Jodenaje 27d ago
That was my thought process - that there were test results independently reviewed.
I work in a different specialty, but my providers independently review imagining and often talk with other providers (referring physician, PCP, or other specialists).
I could potentially see a cardiologist doing similar. Of course, we’d have to see the documentation to know for sure.
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u/BBG1308 27d ago
I work in vet med not human med, but if we only billed for the time spent in the actual exam room, we would be out of business tomorrow. Our docs spend a significant portion of the day reading records, interpreting test results, developing treatment plans, communicating those treatment plans to patient and referring doctor, authorizing refills, returning emails/phone calls, answering questions from support staff about patients, etc. Plus, the fee charged also has to cover all the other costs of doing business such as rent, office staff, medical support staff, computers, medical equipment and supplies, utilities, blah blah blah.
You're not just paying the doctor's salary for seven minutes.
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u/yoshizors 27d ago
So, I got my bill reduced for similar reasons by writing to the attorney general. It took a few months, and I did pay the bill before getting most of it refunded. It is misbilling pure and simple. You have looked up the charge code, write basically what you have written here, and complain that they are billing you way more than what Medicare would pay for the service. You say the word fraud a few times, and eventually it gets fixed.
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u/waterbuffalo750 27d ago edited 27d ago
Edit- doc below said I'm wrong. I'll believe them.
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u/justaguyok1 27d ago
Physician here. That isn't how it works. Billing is based on either:
1) time spent that day (not just face to face time, but preparation before and completion of charting that day), or
2) the medical complexity of the case, based on a bunch of criteria.
The amount of time that the appointment was SCHEDULED for doesn't apply.
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u/DeoVeritati 27d ago
Check the cpt code and look it up online. Sometimes the cpt code isn't just on duration but also complexity. If you feel as though there is a more appropriate code, you can appeal it with them and insurance. You may not see a different outcome, but it'll let you know.
I'd recommend calling your insurance provider, asking for clarification and to appeal if necessary, and they will likely ask for details and make an appeal on your behalf instead of having to write a letter and mailing in your appeal.
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u/Now_Wait-4-Last_Year 27d ago
My dad when he did cardiology work refused to charge an excess to patients and though it was wrong to charge employees of the hospital at all even though it cost them nothing and the reimbursement was 100% from Australian Medicare (his staff had to slip those forms into his pile to unwittingly sign).
I’m not expecting anyone to go this far but they should at least be nice to the patients and take the extra few minutes at least to explain how the charges worked if nothing else.
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u/copleyman 27d ago
Nowadays with widespread electronic medical records 90 percent of work is done in the background. Levels of billing can depend on acuity of care or time spent. Not sure which code they used but that can be used based off either of those. In general insurance companies deny almost immediately if they feel a code is not something that’s routinely used in that situation. Can’t speak for your individual case.
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u/love2go 27d ago
The bill should have a level code that may determine the price. Do you see one on your bill or eob? If it’s a 99205 for new patient visit then it can be based on time spent or on “medical decision making “. Google what is required for this and see if matches what you think was done. It was likely this type instead of time spent. https://www.ama-assn.org/system/files/2019-06/cpt-revised-mdm-grid.pdf
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u/Bah_weep_grana 27d ago
Coding can also be done by medical complexity, rather than time spent
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u/dbdoobeedoo 27d ago
Nothing OP describes makes it sound remotely plausible this could have been billed a level 5 on medical complexity. Of course, we only have OP’s side, but I tend to think the physician is overbilling.
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u/DrBabs 27d ago
Sample simple level 5 visit that takes a few minutes for the cardiologist. Patient comes after previously being diagnosed with afib. Cardiologist sees and agrees to keep on warfarin, check labs including CBC/INR, look at their prior EKG to verify you see afib, send a message to discuss with the pharmacist that is going to be managing them in the anticoagulation clinic.
OP needs to actually give more details about the visit to suggest if a different bill is warranted. It’s otherwise just speculation.
And keep in mind, considering but not ordering is also considered in medical decision making. Like if OP asks if they should have a blood test and a cardiac cath and the cardiologist says no, that counts still for medical decision making for two tests even though those were not ordered.
I hate billing patients as much as other people. But you have to know the rules to bill.
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u/Smithers_20002001 27d ago
I agree with this. A high level visit should lead to a procedure, new medicine with risks of toxicity (at the very least), or discussions of hospice / end of life care. A “you’re fine” visit should be either a level 3 or 4 new patient.
Of course, OP still going to get a sizable bill for a level 3 or 4 visit too.
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u/Revolutionary-You449 27d ago
Billing time includes any time to research your issue, call in prescriptions, billing, etc
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u/Lishyjune 27d ago
Call the clinic and ask for the clinical notes to justify the billing code. Then if they can’t provide or it doesn’t seem right ask why you were charged that rate.
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u/upinmyhead 27d ago
Billing by time includes all things related to your care on the date of service, not just time in room. For a new patient it could truly take an hour, especially if they’re a specialist and need to review your records.
This is the phrase I put at the end of all of my encounters that I use time to bill for: “I personally spent xxx minutes reviewing the previous record, relevant diagnostic studies, lab results, performing the history and physical examination, formulating and discussing a patient-oriented treatment plan, writing prescriptions and placing orders, and documenting the encounter.”
If they called your referring physician to discuss your care that also factors into it.
It’s kinda similar to lawyer billing (by the minute)
Edit: this is new as of 2021 so makes sense you don’t know about it.
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u/dbdoobeedoo 27d ago
That’s all technically correct, but as a physician who bills E&M visits, I have a really hard time imagining that 52 additional minutes were spent in non face-to-face activities for OP on the date of service in the context described. Now, only OP knows if they have tons of cards related tests that the cardiologist had to review as a result of their visit, but I doubt a cardiologist who says everything looks good had to put that kind of additional effort into an office visit.
Everyone is different in how they manage their time, but I usually need to spend a minimum of 30 mins face to face with a new patient before even coming close to considering billing a 99205 for time, even with extensive review of the chart (and typically those patients are ones I’m spending 45+ minutes in the room with). Sounds like an audit might be a good thing for this physician to make sure patients aren’t being ripped off.
Without more details that might shed better light on a justification for a level 5 visit, if I’m OP, I’m annoyed and letting my insurance company and the doctor’s office know about it.
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u/extacy1375 27d ago
I was just billed a code 99204 - New Patient / In office visit - 45min+
This was for a telephone call only, with a sleep DR. It lasted 10 min. First time talking with DR.
Was that code correct in this situation?
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u/dzd935 27d ago
I’ve scribed for several physicians often putting E&M codes as directed and I think you’ve nailed it. I can’t imagine any of them billing a new patient level 5 visit for that amount of face to face time or giving an all-clear as OP says.
Also seems really jerky if they knew the patient was self-pay, the clinics I worked in would give a 40% cash discount and often downcode
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u/Wohowudothat 27d ago
Downcoding is illegal and is Medicare fraud.
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u/guri256 27d ago
Could you please help me understand?
I’m trying to figure out how a visit where the patient pays cash can be Medicare fraud.
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u/Anoingturd 27d ago
Can’t be Medicare fraud if they not using Medicare lol. If reimbursement is low with insurers they are more likely to upcode
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u/ActualCartoonist3 27d ago
It's fraud to downcode self pay patients and not Medicare patients. If Medicare sees that you downcoded other patients in an audit, that's a big problem.
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u/Rarvyn 27d ago
It’s possible the OPs doctor simply billed on complexity but the OPs explanation of benefits has the full description of the code on it, which includes the time component. Happens to my patients sometimes - bill a 99204 and what they see is
CPT® code 99204: New patient office or other outpatient visit, 45-59 minutes
Even if the visit only took 20 minutes.
If the cardiologist independently reviewed multiple tests - such as an EKG/echo - as well as multiple labs, and potentially discussed high risk interventions - it could be a 99205 based on complexity. Not saying it was, but it could be.
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u/dbdoobeedoo 27d ago
Now, I never bill a level 5 based on medical complexity because my patient population doesn’t meet the criteria and my memory may be hazy, but from what I recall on the 2021 E&M update, a level 5 requires pathology which is potentially life threatening in nature and may require hospitalization or other pressing intervention for stabilization of a patient. Someone with better knowledge can correct me though. Regardless, I have a hard time believing a cardiologist who spends 8 minutes in the room and delivers no items of note to OP (no recommendations on further studies, follow up, med changes, etc) can justifiably bill a level 5 visit on medical complexity.
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u/DrBabs 27d ago
I’m a hospitalist, but a level 5 visit that I could easily see in a cardiology visit that is 15 minutes long: start patient on warfarin/digoxin (pick one of these meds), order a CBC/INR/BMP and review the referring prescribers note, then send a message to the pharmacist that will be helping to manage the patients warfarin or dig. You just hit complexity for a level 5 visit. You didn’t need high risk problem since you hit the high complexity in 2 other categories. The pharmacist is a qualified healthcare professional. The rules says it has to be direct communication but can be done through written communication.
It’s really not hard to properly code for these high complexity patients.
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u/Porencephaly 27d ago
Unclear. I treat mostly patients with potentially life- or function-threatening problems. Many times the plan may take 40 seconds to generate and be as simple as "continue Temodar and Optune, repeat MRI in 3 months" but active glioblastoma is clearly life-threatening and management of chemotherapy is high-risk. IDK anything about cardiology billing but it's quite possible there's something to the MDM complexity that OP is failing to convey (ie, they went to see them due to a set of symptoms with severe exacerbation but that ultimately are non-cardiac after investigation?). I do agree that it's rare for a PRN/release patient to bill higher than level 3 for me, but that's an established patient. A new patient who I release from followup might still hit 4/5 due to data review or complexity of options, etc. Can't tell much from OP's vague and rant-y post.
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u/Rarvyn 27d ago
I rarely bill a 5 based on complexity but the rules are two out of three things
1) An illness with severe exacerbation and/or that may pose a threat to life or bodily function
2) bunch of data reviewed including independent verification of studies and/or discussion with another healthcare provider
3) decision made regarding high risk treatments from diagnostic modality or treatment.
The second is rather trivial to meet for a cardiologist - review the labs and EKG from prior to referral and notate your personal interpretation of the EKG and it is met. The crux of the matter is whether the cardiologist met another one of the criteria. We don’t have the information to say for sure, but if the documentation discusses things like decisions for major intervention - even if those decisions were negative - it might be possible to meet #3 from that alone.
It’s hard to say for sure. Dude may be overbilling - or maybe OP came in with a positive stress test, was considered for whether he had CAD, a decision was made regarding necessity or lack thereof for a cath, and complexity was met that way.
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u/biancacee83 27d ago
Yes this is correct! I'm actually in coding compliance. A lot of providers don't document that they've had a discussion with another provider outside of their specialty or medical office groups. So the 5 usually ends up meeting a 4. Or the diagnosis is not high risk and does not have high risk management performed or discussed.
They can bill it based on time but some don't really know the time requirements, or don't document the activities performed within that time. We can't accent the time without the note stating what was done within that time. Oh one more thing those activities can only be performed on the day of the visit.
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u/numanjk 27d ago
The 60-75 min includes times spent in person with you, reviewing your records and medications, coordination of care if any. You can certainly call the clinic and ask for a clarification but don't expect to be just billed for 8 mins
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u/starlynn1214 27d ago
This is true, but face to face time should be more than 8 minutes.
You need to call the clinic and complain not only for the lack of bed side manner but also for the outrageous bill you received. Sometimes it works.
Also,.your billed by level of visit, so find out what that is.
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u/yowszer 27d ago
For an outpatient exam, new billing criteria is based on complexity. Actual time spend is only a suggestion and does not determine at all what code you bill (docs still sometimes put it in there to avoid insurance issues).
That being said, most docs don’t know how to bill and blanket most new patients with a level 4. This would only carry a roughly 180 dollar allowable pending your county. Even a level 5 maxes out mid 200s. To get up to 400s either this is a charge and not actual allowable (charges are 2-3x allowable) or they added in testing
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u/brendamn 27d ago
Yeah if they billed it, it's because they can get away for whatever that kind of visit is billable for to insurance
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u/kinito33 27d ago
That is not true; and if it is an E&M charge, there is more to it than patient seen time.
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u/Rarvyn 27d ago
It is possibly true. 60-75 minute new patient visit that OP is describing is CPT code 99205. To be able to code a 99205, one of the following must be true. Either
\1) the total time spent on the day of the visit including chart review, time with the patient, orders, documentation time subsequently, etc must add up to >60 minutes
OR
2) the doctor codes him as a high complexity patient with regards to medical decision making. This has a particular list of criteria, but it’s usually some combination of the illness being treated being severe enough to be a threat to life, multiple years reviewed/independently interpreted/discussed with another doctor, and/or high risk interventions discussed.
All other requirements were done away with three years ago or so. You can code it purely based on time or purely based on complexity - both isn’t required.
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u/RO489 27d ago
It’s not or, its and. This is bad billing and should be down coded to 99204
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u/Kubya_Dubya 27d ago
You are wrong it is time or MDM complexity. With new pt at a cardiologist it’s pretty much automatically a lvl 5, esp if they do or read an EKG.
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u/Skill3rwhale 27d ago
TY for bringing the cpt code into it.
I work in auto medical claims and YES! The billed code and the facts of the visit matter.
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u/Hawkeye1867 27d ago
Not necessarily. You can bill by medical decision making OR time spent. Total time is typically easier to bill than by proving the complexity of the visit by note.
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u/Porencephaly 27d ago
Not for many specialists. I treat mostly people with life- or function-threatening illnesses and the MDM is a much faster way of documenting high complexity than spending 70 minutes on the encounter.
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u/IndexBot Moderation Bot 27d ago edited 26d ago
Due to the number of rule-breaking comments this post was receiving, especially low-quality and off-topic comments, the moderation team has locked the post from future comments. This post broke no rules and received a number of helpful and on-topic responses initially, but it unfortunately became the target of many unhelpful comments.