Friday, April 19, 2013

Pediatrics: Sick and Well Visits on the Same Day are NOT Double Billing

The other day I read a blog post about physicians double billing. The article was posted on a blog of a reputable company  but the content was outrageous and it has driven me to a reply. First, about the article to which I am referring…

The author complained that when he took his child to the pediatrician for a well visit and an ear infection was discovered during the visit, his insurance was double billed. He claimed to have called the insurance and was told it was a legitimate practice. Regardless, the author blogged a complaint saying that the  physician was double billing in a blog post.

First, I want to take a second to talk about the technical aspects of what happened in this situation and why the physician’s billing practices are completely legitimate. Following that, I will point out the common sense perspective.

When a child sees their pediatrician for a well visit, the physician is responsible for performing and documenting a physical appropriate to the child’s age. A physical for a child generally includes various measurements (height, weight, etc.) and examinations to make sure that the child is growing and healthy. The physician will check through the child’s history, make sure that all necessary immunizations have been administered and make recommendations (or answer questions as appropriate) on nutrition, sleep , exercise, life-style, etc.  During the well visit, the physician is examining the child for physical health, mental health, and developmental health. The physician is responsible for documenting all of this and, if documented, well visits are a complete service which can and should be billed.

If the physician happens to find a problem, the physician must address that problem and a distinct sick visit begins. A sick visit also has specific requirements for the history of the present illness, review of systems, history,  examination, and medical decision making. All this must be performed (or if already performed it must be reviewed/considered in the context of the sickness) and documented. As the sick part of the visit is a distinct and separately identifiable service, it is separately billable with the modifier 25.

So, why is this practice legitimate? Because two separate services were performed. Think of it this way (here’s the common sense part). If you take your car in to the mechanic for a routine oil change, the mechanic will bill you for the oil change (a well visit). Now, what if, during that oil change, the mechanic discovers that there is a crack in the oil pan. If the mechanic repairs/replaces the oil pan to fix the problem (a sick visit) would you expect that repair for free since he/she was in there anyway? No! You would expect that the mechanic would bill for BOTH services. If you wouldn't expect a mechanic to give away free services, one cannot expect a physician to perform additional services for free.


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