Explanation of Visit Types

The different types of visits and the coverage of them by insurance is potentially very confusing and frustrating (for me as well as for you). We strive to make every visit useful and meaningful while working within the constraints mandated by insurance rules that govern what we can do and how we are paid for our services. Hopefully, this section will clarify some of the visits that we provide.

Physical/Check Up (Well Man or Well Woman Exam)

An exam on a healthy person with no symptoms to look for hidden disease and give advice on healthy behavior. Getting the right preventive services at the right time can help you stay healthy by preventing disease or by detecting a health problem at an early stage when it may be easier to treat. This includes a review of preventative services recommended for your age, gender and state of health. If services such as immunizations, cancer screenings and other preventative services are recommended, they will be discussed, ordered or performed at this visit. For women, this exam can include the annual gynecological exam.
Does Not Include: Medication refills, evaluation of new symptoms, or management of chronic problems.
Insurance Coverage: Covered by most insurance. Not covered by Medicare, but may be covered by secondary insurance if Medicare patient has that.

Well Child Exam

A visit of a child that is age-specific to review growth, development, immunizations, and as a time to educate on what to expect for the developmental stage and for injury prevention. These visits are covered at specific ages that are more often in the first 3 years then annually after that. The content of the visit follows the Early Periodic Screening, Diagnosis, and Treatment (EPSDT) Program guidelines.
Does Not Include: Sick child care, evaluation of new symptoms, medication refills
Insurance Coverage: Covered by almost all insurance, including TennCare.

Follow Up/Chronic Care Visit

A visit to review chronic problems, adjust medications, check laboratory monitoring, or refill prescriptions. For some simple chronic problems (e.g., allergies), this may be once a year. For more significant problems or uncontrolled problems, it may be as often as needed to work toward controlling the problem.
Does Not Include: Review of preventive services.
Insurance Coverage: Covered by almost all insurance, including Medicare and TennCare.

“Welcome to Medicare” and Annual Medicare Wellness Visit

Specialized planning visit to review which Medicare preventive services you need. Medicare requires that a standard set of questions be asked. They must include: review of functional status, depression screening, list of special medical equipment (if any), and list of other doctors. At the end of the visit, you receive a written summary of the services you require that are covered by Medicare. These might include cancer screening tests, EKG, blood tests, bone density tests, ultrasound, etc.
Does Not Include: Medication refills, management of chronic conditions or evaluation of new symptoms.
Insurance Coverage: Medicare pays in full. There is no co-pay or deductible.

Urgent/New Symptom Visit

An appointment to investigate a new symptom or urgent need—such as chest pain, sore throat or infection. This may be simple or quite complex depending on the symptoms and general state of health. Due to the nature of the visit, it is often required on the same day. Depending on the complexity, a second visit may need to be scheduled after initial testing is completed.
Does Not Include: Medication refills for other problems or review of preventive services.
Insurance Coverage: Covered by almost all insurance, including Medicare and TennCare.

Administrative Physicals

Camp physicals, school physicals, work physicals, insurance physicals—this type of visit requires the doctor to fill out a form. Services include whatever is necessary to fill out the form.
Does Not Include: Medication refills or evaluation of new problems.
Insurance Coverage: Sometimes covered by insurance, but often not. In cases where a form is needed a short time after an appointment (i.e., child had an annual Well Child Exam to update immunizations and three months later needs a form filled out for camp), the doctor may be able to complete the form without another visit. However, there is a fee to fill out the form and that fee is usually not covered by insurance.

Coding for Your Insurance

The difference between medical services is sometimes hard to understand. The physician practice does not control these differences. Our reimbursement is based on the coding system that insurance companies use to describe medical work. For example the coding system classifies a physical exam and medication refill as two separate services. In order to properly submit bills to the insurance, we have to follow the rules put forth by the coding system. How the insurance reimburses the service is defined by the terms of the patient’s policy.

Can I combine services?

For your convenience, the provider may combine two types of services at one visit — a Well Man Exam and a chronic care visit to refill blood pressure medication, for example. Many factors determine if we are able to do this at a particular visit: how well a medical condition is under control, if there is a new more urgent problem that requires in-depth evaluation, the general health of the patient and the time allotted for the visit. However, because these are two different services, there would be two separate charges. We may collect two co-pays at the time of your visit and submit two charges depending on your insurance benefit.

How do you decide what to focus on during an exam?

Focusing the exam is very important (but often very difficult) to make sure that the visit is as productive as possible. Often there are two (or more) agendas that compete for time and attention. The patient may have specific concerns on the day of the visit, the physician may need to check on the status of chronic conditions and address the issues that may not be causing an immediate problem but have the potential to cause problems in the future, and the need to keep up with prevention is ongoing. In addition, sometimes clues arise while talking to the patient or during the physical exam that require further investigation, occasionally moving to the top of the priority list. All of these focuses are important and need to be addressed, but it is sometimes too much to adequately handle in one visit. Because of this, it is very important to communicate about the goals of the visit and work together to have an effective visit.

How do you decide what tests and services I should have?

Providers are specially trained to evaluate the usefulness of tests and preventive services and help you decide which ones are right for you. We offer advice on immunizations, X- rays, blood tests, and a host of other special procedures. Generally, testing is based on your age, health history, and risk factors. We rely on information from the United States Preventive Services Task Force to guide our recommendations.