The U.S. Department of Health and Human Services (HHS) through the Centers for Medicare and Medicaid Services (CMS) in association with the American Medical Association (AMA) establish and publish coding regulations used by Medicare and private insurance carriers to process medical claims. PAMF follows these published guidelines when it submits claims, and this may affect your bill.

By law, medical providers like PAMF must accurately specify the type of treatment they provide to a patient, whether preventative or problem-related in nature. Health insurers base their coverage determinations from the procedure and associated diagnosis code(s) submitted for claims processing.

As a result of these federal guidelines and regulations, your provider may charge for both a preventative service and a problem-related office visit when both services are performed during the same visit and properly documented in the medical record. Please be assured that the quality of care you receive will not be affected.

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

Federal guidelines specify that a provider must charge for preventative care, such as an annual physical exam, separately from problem-related care, (i.e., sprained ankle or high blood pressure) when both services are performed at the same visit. Therefore, if you receive treatment for a specific health problem during your physical exam, your physician is bound by established coding regulations to submit a separate charge for this service.

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

According to the regulations, these services cannot be combined because they are not the same service and are considered unrelated. Most health insurers also abide by these same regulations and consider preventative care and problem-related treatment to be different services. They are therefore willing to pay for these services separately. However, it is important for you to check with your insurer prior to your visit to find out specifically what your insurance covers. Some insurance carriers, especially Medicare, have strict limitations regarding coverage for preventive services.The patient, his/her employer and the health insurance carrier are the only ones who know or can verify insurance coverage. PAMF providers and its Business Office staff do not have access to this information.

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 evaluates your overall health by taking your relevant medical and family history, asking pertinent screening questions, and performing or ordering appropriate screening tests based on your age, sex and medical risks. 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 CMS, which was established by HHS. The AMA guidelines also define this as a correct billing practice. Ethically, providing both services during one appointment uses your time and your provider'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. It can also be a cost-saver for the patient since often only a single office-visit copay would apply as opposed to the two office-visit copays that would apply if the services were provided at different appointments.

This is a nationally recognized standard practice for medical billing and coding.

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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