Understanding office visit and billing practices
As a Patient Centered Primary Care Home, East Portland Pediatric Clinic is committed to providing and maintaining the best possible care for our patients. Your review of billing practices in advance, allows for good communication and common understanding.
Medical offices that take insurance get paid by coding what they do. These codes are designated by the Center for Medicaid and Medicare Services (CMS) for all types of insurances.
- G2211 is a new code from CMS created for primary care providers to indicate that they are following patients longitudinally and are committed to caring for the whole patient over time. The pediatricians at East Portland Pediatrics take pride in providing continuity of care. This code is added to all patient encounters except those designated as Well Child Checks. Please contact your insurance company if you have questions on how they process this code.
Insurance company billing policies dictate that we differentiate
between two types of services.
- Wellness Services
- Problem-Oriented Services
What may be included in Wellness Services (also known as
preventative visit or physical or well child check)?
- Age appropriate history
- Age-appropriate medical exam
- Review and interpretation of any recommended labs
- Preventive counseling (such as proper nutrition)
- Review of vaccine history
- Anticipatory guidance (such as reducing fall risks for early walkers)
What other preventive related services will be billed separately?
- Vaccine products
- Routinely recommended labs**
- Vaccine administration services (including counseling)
- Screenings, (e.g., vision, hearing or developmental screens)
The Affordable Care Act makes many wellness and/or preventative services covered in full by most insurance plans. However, this is not true of many problem-oriented services. Management of medical diagnoses, including the need for medication refills of any sort, are categorized by insurance companies as problem-oriented services. Evaluation and/or management of any complaint and/or symptom offered by a patient or identified upon questioning during a wellness exam constitutes a problem-oriented service which may result in your insurance company processing your claim using both wellness benefits and problem-oriented benefits.
Problem Oriented Services
Some common examples of problem-oriented services include but are not limited to:
- Illness addressed (ears, eyes, nose, throat, cough, fever, etc)
- Chronic conditions addressed (obesity, asthma, ADHD/ADD etc)
- Management of Medication refills(e.g., obesity, asthma, ADHD)
- GYN concerns
- Lactation Services
- Suture Removal
- Anxiety/Depression
- Nail Excision
- Behavior Concerns
We perform all screens recommended by the American Academy of Pediatrics seeking to uncover any conditions that would lead to suboptimal health in years to come. Some Insurance plans consider screens as a problem-oriented service and may generate cost sharing in the form of copayment, co-insurance and, or deductible. Examples of screening services include but are not limited to:
- Vision tests
- Hearing screening
- Developmental Screening (ie: 9, 12mo questionnaires)
- Mental Health questionnaires
- Adolescent questionnaire
- Autism screening (MCHAT)
- Spirometry
- Cholesterol, Lead, Hemoglobin Screening
**all laboratory, radiology and/or pathology services performed or referred by our providers may result in additional bills and/or charges from other companies that may include but are not limited to: Quest, LabCorp, Epic Imaging, Adventist lab etc.. You may receive separate billing statements for these services.
Our medical practice wants to provide the most up-to-date, comprehensive care possible, which is why we address these issues during wellness visits. Additionally, we try to eliminate the need for the patient to return to the office, whenever possible. It is the responsibility of the policy holder to be aware of their insurance plan’s benefits and coverage. Deductible, copay, coinsurance or out-of-pocket expenses agreed upon between you and your insurance company are out of our control.