Allowable fees will depend on the number of issues addressed in the clinic visit, the extent of history taken and documented, and the responsibility for each issue taken by the primary care physician. Some additional fees will be allowed for episodes of care beyond a straightforward office visit, which will be a function of the time and expertise required to provide these services.
Fee Structure
The fee structure for face-to-face encounters will be based on the following three levels of care for each issue addressed that reflect the thoroughness of the Primary Care Evaluation and the level of responsibility accepted for each issue (IA stands for Issues Addressed):
| Billing Level | Full Responsibility Thoroughness Levels |
Approximate Time for the Initial HPI and ROS |
Assumed Total Time for HPI/ROS and Assessment/Plan |
| IA-3 | Thorough | 2.5 – 3.5 minutes | 6 minutes |
| IA-2 | Moderate | 1.5 – 2.5 minutes | 4 minutes |
| IA-1 | Brief | .5 – 1.5 minutes | 2 minutes |
Thoroughness
Based on patient or physician preferences, it is reasonable in a given clinic visit for an issue to be addressed thoroughly, moderately, or briefly. For instance, a patient may need her diabetes medicine refilled, but is in a hurry and prefers not to cover all aspects of diabetes care that day.
While it is difficult to be precise in defining thorough versus brief, the most important element is the time spent in the conversation between doctor and patient. For symptoms, this is defined by the HPI. For chronic disease care, this is defined by the elements of chronic disease care. See Documentation Guidelines.
Each issue addressed should be billed at the proper level of thoroughness independent of other issues. For visits where multiple issues were addressed, a cross check of the total amount of time spent in conversation with the patient (not counting documentation time) may help guide individual issue codes. These times could include taking a history/ROS, reviewing old records, labs, or imaging results, explaining the assessments/diagnoses, and negotiating treatment plans.
Billing Codes
Issues Addressed Codes
The physician may bill for each issue addressed. The number of issues actually addressed in the physician-patient encounter is the result of a negotiation between the two parties, but is almost always ONLY the issues the patient wants addressed. Each issue must exist as a standalone concern. This concept is covered in more detail in the Primary Care Evaluation and Management Services Operations Manual and the section in this document on Professionalism.
In general, preventive services are not covered as separate issues. These should have been addressed in the initial new patient visit (new to the SENTIRE system) and with each year’s registration renewal.
Extra Time Fees
There are clinic visits when a physician must spend time beyond a standard visit to provide the best care. For example, some patients may have a long list of questions they want answered that require more than a few minutes of physician time. Another example is a prolonged discussion of a patient’s end-of-life wishes.
The following activities may be billed for the extra time required to complete each task. These conversations may include the patient and/or other important people in the patient’s life. Further details are provided in the SENTIRE Operations Manual.
| Extra Time Activity | Code |
| Extra Time Codes for Face-to-Face Encounter | |
| Advance Directive Discussions | ET-ADD |
| Acute Disease Treatment | ET-ADT |
| Family or Friend Concerns | ET-FFC |
| Unusually long History | ET-HIS |
| Unusually long Shared Decision Making | ET-SDM |
| Other Direct Patient Care Not Necessarily Face-to-Face | |
| Fill Out Forms | ET-FOR |
| Look Up Best Diagnostic/Treatment Options | ET-LUP |
| Review Previous Medical Records | ET-RMR |
| Extra Time at a Reduced Fee | |
| Diabetes/Diet/Exercise Counseling | RF-DDC |
| Primary Mental Health Counseling | RF-MHC |
Example
Let’s say a patient wanted the family physician to address diabetes and asthma, and the doctor did so thoroughly for each. But on this visit, the patient had 15 minutes of questions, so the total conversation took about 20 minutes. The total maximal time falling under the IA codes are listed in the chart above. In other words, this is the expected time a typical visit would take for the doctor to interview a patient, then engage in the shared decision making of the assessment and treatment plan. In this case, the time covered by the IA codes would be 2 Issues Addressed at 6 minutes each. Therefore the doctor is allowed to bill an additional 8 minutes of extra time spent conversing with the patient and family. How he wishes to classify the exchange is at his discretion.
Information Management Fees
Primary care physicians must often provide cognitive work on behalf of an individual patient occurring at different times from face-to-face visits, or even at different times from a telephone conversation or email exchange. This work includes medical decision making, medical-legal liability, and communication with many other components of the health care system. However, it is often work that occurs in small frequent units of time that would be administratively burdensome to identify and bill separately. Information Management Fees allow the physician to anticipate and bill for these expected tasks at the time the inciting event occurs.
| Advanced imaging management | IM-AI |
| Lab and X-ray management | IM-LX |
| Chronic prescription management | IM-CP |
Other Allowable Fees
SENTIRE includes other fixed fees for common office expenses. Briefly, they include:
- Injection Fees – These are similar to allowable rates by Medicare and commercial insurers.
- Point-of-Care Tests – These are priced on the lower end of common commercial rates.
- Well Child Visits – These are prices similar to common commercial rates. Injection rates for vaccines are allowable also.
- Annual Check Up – A pure annual check up with no particular patient concerns to address should not be the norm. Preventive services should be addressed when the patient pays the annual registration renewal fee, and can commonly be addressed without an office visit. However, SENTIRE recognizes that patients will sometimes request an “annual physical”, but prefers the label “annual conversation”.
- Pelvic Exam – SENTIRE recognizes that a pelvic exam for any reason requires time and some equipment, so a separate pelvic exam fee is allowed.
- Prolonged Counseling – SENTIRE recognizes that extended counseling for behavioral health concerns are sometimes provided by family physicians. A fee for these services is allowed for each minute beyond a thorough assessment of the issue(s). This fee reflects charges commonly billed by various forms of licensed behavioral therapists.
- Common Written Screening Tools – SENTIRE recognizes that common screening tools such as MOCA, MMSE, PHQ-9, GAD-7, Newest Vital Sign, and so on require extra time for the physician to interpret the results and discuss with the patient. Small fees are allowed, differentiated by the number of questions on the instrument.
- Procedures – SENTIRE allows procedure fees that are roughly equivalent to those of Medicare. Other allowable charges should be guided by common rules developed by Medicare and other payers (for example, lidocaine and guaze are part of common procedures and should not be billed separately).
- Other Supplies – Other supplies such as antibiotic injection vials, vaccine vials, IUDs, and eye drops can be billed at the physician’s actual acquisition cost plus 10%.