How We Bill

The National Correct Coding Initiative (CCI), which establishes and publishes the coding regulations used by Medicare and all insurance carriers with which PAMF contracts, has instituted rules that may affect your bill. Physicians must specify the type of treatment they provide to a patient, whether preventative care or problem-related care. Health insurers look at these codes when determining what services they will cover.

As a result of these federal guidelines and insurance practices, your physician may charge for both preventative services and a problem-related office visit if you are treated for a specific health problem during your visit. The care you receive will not change and your physician remains committed to providing you the highest-quality care.

Why might my physician charge for two services at one appointment?

The CCI specifies that your physician must charge separately for preventative care, such as a physical exam, and problem-related care, such as a sprained ankle or hypertension. Therefore, if you receive treatment for a specific health problem during your physical exam, your physician is required to charge separately for these services.

Why can't these two services be combined if they occur during one appointment?

According to the CCI, these services should not be combined because they are not the same service. Health insurers also do not consider preventative care and a problem-related treatment the same service, and therefore pay for them separately. However, it is important to check with your insurer to find out the specific coverage they provide.

What are the basic differences between a physical exam and an office visit?

A physical exam is a preventative health maintenance exam during which your physician takes your relevant medical and family history; asks pertinent screening questions; and performs or orders appropriate screening tests based on your age, sex and medical risks to evaluate your overall health. On the other hand, a problem-related office visit addresses a specific health problem through discussion, examination, diagnosis and/or testing, and treatment is prescribed as necessary.

Is charging for two services at one appointment a standard, ethical and legal practice in health care?

Yes. Legally, it is defined as a correct physician billing practice by the CCI, which was established by the federal Department of Health and Human Services (HHS). Ethically, providing both services during one appointment uses your time and your physician's time effectively and generally means that the problem-related office visit may be charged at a lower fee than if it were provided at a separate visit. Also, it is a standard practice in medicine.

What if I have further questions about the services I am receiving?

Your physician is happy to answer any questions about the services you are receiving. If you have specific billing questions, please contact Patient Accounting at (650) 812-3838.

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