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Healthcare Price-Transparency Fundamental for Doctor’s Office Visits

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Even something as simple as a doctor’s office visit can be complex from a price-transparency perspective.  An in-network doctor will have entered into a contract with an insurance network and they will have agreed to a fee schedule.  That fee schedule will be based on the CPT procedure code for the visit.  All office visits, tests and procedures in healthcare are billed using a 5 digit CPT code that serves as the unique identifier for that visit, test or procedure.  Most doctor’s office visit fall into one of two major categories: New Patient Visits and Established Patient Visit.  Those two categories are then further broken down into ‘Levels’ based on the time duration (number of minutes) and complexity of the visit.  Sometimes these office visit codes are referred to as E/M codes as well—E/M stands for Evaluation and Management.

Below are a list of some Office Visit CPT Codes, their ‘level’ description and ‘ballpark’ allowed amount (could be higher or lower depending on your particular insurance network and depending on the particular type of doctor)

New Patient Office Visit:

  • 99201 – Problem Focused – $37
  • 99202 – Expanded Problem Focused – $65
  • 99203 – Detailed – $97
  • 99204 – Comprehensive, Moderate – $137
  • 99205 – Comprehensive, High – $175

 

Established Patient Office Visit:

  • 99211 – Minimal – $21
  • 99212 – Problem Focused – $38
  • 99213 – Expanded – $55
  • 99214 – Detailed – $82
  • 99215 – Comprehensive, High – $120

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