Wednesday, November 5, 2014

Knowing Your Benefits: In-Office Procedures

The great thing about coming to Lake Washington Sports and Spine is that for many patients we are a “one stop shop”.  A consultation at LWSS includes a guided interview with a physician, followed by a physical examination, to help diagnose a chief complaint and determine the next best step.  Our physicians not only provide a consultation but also have the capacity to perform in-office (or outpatient) procedures saving the patient an extra trip to a different location for another visit.  Some health insurance policies require a co-pay up front, which can cover the consultation portion of a visit...but what if you have an in-office procedure in addition to the consultation?

Some of the procedures that may be performed during an office visit are:

·         Diagnostic testing -including ultrasound and electrodiagnostic testing 
·         Ultrasound-guided injections -including but not limited to  joint, tendon, and bursa injections, viscosupplement, prolotherapy and platelet-rich plasma

Most procedures done in-office are going to be subject to your insurance policy deductible and co-insurance.  Prolotherapy and platelet-rich plasma injections are non-covered under any health insurance policy, these are self-pay procedures.
What is a deductible and what is co-insurance?

·         Deductible -a set amount that you must pay each year before your plan pays for certain services such as outpatient procedures, hospitalizations, and radiology. You meet this deductible once each calendar year.
·         Co-insurance -your share of the fee for a service in the form of a percentage.  If your plan’s coinsurance share is 20%, you pay 20% of the allowable charge and your health plan pays the remaining 80% of the allowable charge.

For example:
New patient Wynnie Smith gets referred for a consultation and ultrasound for shoulder pain, and she has Regence Bluecross Blueshield insurance.  The physician takes her through a consultation of the shoulder pain, and additionally performs a diagnostic ultrasound procedure to check the muscles, ligaments and tendons surrounding the shoulder.  After discussing various treatment options, the physician advises an injection of corticosteroid (Triamcinolone) in the subacromial bursa to ease some discomfort.  As there is time left in the appointment to perform this procedure, Wynnie elects to have the injection.

For example (What we would bill to Regence Bluecross Blueshield):

CPT Code 99204 (New patient consultation) subject to co-pay OR deductible (based on individual policy)
CPT Code 76881 (Diagnostic Ultrasound) subject to deductible and co-insurance
CPT Code 76942 (Ultrasound guidance for the injection) subject to deductible and co-insurance
CPT Code 20610 (Arthrocentesis, aspiration and/or injection, the actual “injection” code) subject to deductible and co-insurance
CPT Code J3301 (corticosteroid-Triamcinolone, medication injected) subject to deductible and co-insurance

While your first reaction may be “Whoa! That’s a lot of charges!”, consider this:  When visiting LWSS, you really are getting the benefit of an all-inclusive experience.  A patient can receive not only a top-notch consultation by a specialist but also a diagnostic procedure and injection all within the same appointment.  By having the capacity to perform these in-office procedures all at one location, you’ve just saved yourself 3 separate visits. 

It’s important as a patient that you take ownership of what your benefits are ahead of time, so if and when you have an in-office procedure you know what your deductible amount is and what your co-insurance responsibility will be after the deductible has been met.  I encourage you to contact your health insurance provider for that information and as always I wish you well on your path to staying active!