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.
