Office Visit Fees Explained: What Every Patient Needs to Know

Have you ever gone to a follow-up appointment or a quick procedure and wondered why you were charged an office visit fee on top of everything else?

In this episode of Take Care, Melody Mulaik answers a listener's question about when it's appropriate for healthcare providers to bill an office visit separately from a procedure. She explains how surgical global periods work, when follow-up visits should already be included, and why some procedures may not require an additional evaluation and management (E/M) visit.

Understanding these billing rules can help you spot potential billing errors, ask the right questions, and avoid paying for services you shouldn't be charged for.

What You'll Learn In This Episode:

• What an office visit (Evaluation & Management) charge actually covers
• Why some post-surgical follow-up visits should already be included
• The difference between 0-day, 10-day, and 90-day global surgical periods
• When an office visit can legitimately be billed with a procedure
• Why does removing a mole not automatically justify an office visit charge
• How does bringing up a new medical concern change billing
• When physical therapy is billed separately
• What to do if you think you've been billed incorrectly
• How your insurance company can help review questionable charges
• Tips for advocating for accurate medical billing

Timestamps:

• 00:00 Listener question: Why am I being charged an office visit every time?
• 01:00 Understanding post-surgical follow-up billing
• 01:45 What are global surgical periods?
• 02:30 The difference between 0-day, 10-day, and 90-day global periods
• 03:15 When follow-up visits should be included
• 03:55 Why physical therapy is billed separately
• 04:15 Billing rules for mole removal and minor procedures
• 05:00 When a new medical concern creates a separate office visit
• 06:00 How providers determine whether an office visit is billable
• 06:45 What to do if you believe you've been billed incorrectly
• 07:30 Final advice on advocating for accurate medical billing

Have a healthcare billing or insurance question you'd like answered on the podcast? Visit our website and submit your question for a future episode.

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Transcript

Melody 0:11

Hello, everybody, and welcome to this episode of Take Care. This week's episode comes from a listener question. Michelle wrote in and said, "I had surgery a few months ago, and every time I go back for a follow-up, I get charged an office visit on top of everything else. Then last month, I went in just to have a mole removed, and I got billed for that visit too. Is this normal? Should I always be getting charged a visit fee just for showing up?" Michelle, that's a really great question, and the short answer is no, you shouldn't automatically be billed a visit every time that you go to see your doctor. It really depends on some details. So we're going to break down these couple of scenarios a little bit differently. The first situation, you mentioned a post-surgery follow-up. One of the things to keep in mind, for every surgery that somebody has, whether it's a minor surgery or major surgery, the payment for that surgery includes a certain amount of pre-work, as we call it, or the work that's done preparing you for that surgery, and so it's pre-work, and then also some follow-up. Now, really minor procedures, as we call them, everything's included in that day. So anything that happens after that particular day is separate and distinct, and that is allowed to be billed for. So if you just had a really minor procedure done, then it would be appropriate for you to get a office visit billed for going back to see that provider. There's other ones. There's two different time periods. One is called a 10-day period. The other's called a 90-day period. And you might say, "Well, how in the world would I know this?" Well, couple ways. One, you can ask your physician or your provider when you go in for surgery and say, "Hey," you know, they call them global days, "What is the global day period for this procedure?" And they might look at you and go, "Oh, I didn't know if you knew what that was." And they'll tell you. They'll say it's zero, or it's 10, or it's 90. Generally, for larger surgeries, elective, non-elective, you think about joint replacement, you think about a lot of anything that's kind of an open procedure. A lot of those, not all, but a lot of those fall into that 90-day period. So we'll just use joint replacement as a great example. Those are 90-day global periods. So if you get your hip replaced, or your knee replaced, or have other types of major surgery orthopedic-wise, for 90 days, all of those visits that you have when you go in to see your physician or their assistant, or PA specifically, physician assistant, is going to be included in that 90-day global period. Now, one thing to keep in mind is that only relates to the specific surgery or that specific thing they were treating. If you have a new problem that gets addressed, then that's separate and distinct, but anything related to that surgery and any follow-up associated with that is all included in what's called that particular surgical period. So if you go in just for a follow-up visit, and again, no new problem. I mean, pain in that particular area is still part of that problem, right? As long as you're not saying, "Well, my ankle hurts," right? Or "My hip hurts and I got my knee done." So again, separate and distinct. But as long as it's still focused in that area, you should not get a separate visit charge for going in to see your particular physician. Now, that's different from physical therapy, right? Physical therapy is a different service. It is appropriate to be billed for those particular services. So that's the first thing that you want to ask for those particular procedures or things that come into play. So again, if you're in that window, you should not be getting a separate bill if you're in your follow-up period for that particular surgery. The next one is a little bit more complicated or a little bit more nuanced. So they're a question related to going in and getting a mole removed. And you know, in that particular situation, let's say it's a different doctor, it doesn't matter. But you're going in, you're getting a mole removed. Should you get a office visit for coming in to get that particular minor procedure? Well, again, it depends, right? In order to get billed for an office visit, whatever the specialty is, when you go in to see that physician, whether it's your internal medicine doctor, your specialist. To be billed for a visit, they have evaluated your history, they've typically done an exam, they're making some medical decisions about your care, right? It's separate and distinct from that procedure that was done. So procedures are separate and distinct from that. Dermatology is a great example. If I'm just going in to get a procedure done, and we know I'm coming in to get that particular procedure done. It's kind of hard to make that argument for there also to be a visit, again, unless you bring up something new. If you bring up something new of, "Gee, I know I'm here to get this mole removed, but by the way, I've also found this spot in a different location, or I need you to evaluate this." Now you've introduced something that defends having a visit. Any physician practice should not automatically be billing a visit every time somebody comes in to get a procedure if they know that's the whole reason for being there. I know for me personally, sometimes I have to get steroid injections, you know, into my wrist or into an elbow because I have some chronic pain in those areas. I go in sometimes, and it's like six months on the dot. And it's "Okay, I'm here to get that injection," and that's what I get billed for. I get billed for that injection because there's really not a whole other discussion. Now, if I'm going in new, and I say, even though I see that doctor very frequently, and I go in and I say, "Gee, my right shoulder's really hurting me. I know you're going to inject my left wrist while I'm here, but I need you to look at this." And then he does a whole evaluation of that right shoulder, I'm going to get billed for a visit of that evaluation that he did of that right shoulder in addition to that injection in my wrist. Now, he could potentially evaluate my shoulder and also do an injection in my shoulder in the same visit, and that's totally appropriate. But there's going to be not only documentation but the work that was done for that evaluation in the shoulder in addition to it. So the short way to look at it is How-- what is done above and beyond the actual procedure itself in the office? 'Cause that's really where it comes as a question is for that office visit. When that procedure is done, what is separate and distinct? And if there's really nothing separate and distinct, then really they shouldn't be billing you automatically for an office visit. So it's worth a discussion with your physician office of, "Why did I get this bill?" I will tell you that sometimes the response, 'cause I've encountered this as well, the response is, "Oh, that's just what we do." That gets tricky because you're now challenging the whole premise of their billing process. And frankly, it's an incorrect billing process in some cases. So it's worth discussing with your physician. And if your physician or the staff are just adamant that they're going to automatically be billing you for an office visit. I hate to say it, but sometimes you got to talk to your insurance company about it. And you got to let them know and go, "Hey, you know, I went in, I just got this. I noticed they billed me for a visit. I don't think that was totally appropriate, is that something that you can look at?" 'Cause they can request documentation, and they can look at it to see if it is justified. So it's not an automatic situation where they should automatically be billing you a visit. Again, the visit needs to stand alone, and the procedure needs to stand alone. So great questions, and I think that's something that a lot of people deal with. Dig into those details. Make sure that you feel it's justified, separate, and distinct. Partner with your insurance company as you can, as needed, and make sure that you're not overpaying for something. Again, it's a balancing act, but you have to advocate for correct billing for your own behalf. Or if you're doing that for a family member or a loved one, make sure you're taking those extra steps for them as well. So, thank you, Michelle, for that question. And if anybody else has a question they'd like for me to answer, please go to the website and put that information in. I would love to hear from you. Until next time, take care.