An office visit (OV) in healthcare is a face-to-face encounter between a patient and a qualified healthcare professional, such as a physician, physician assistant, or nurse practitioner. This encounter typically takes place in a non-hospital setting, like a clinic or a private office, for evaluation, diagnosis, or management of a health condition. The OV serves as the primary mechanism for delivering ambulatory medical care. This type of visit is distinct from services provided in an emergency room, inpatient hospital, or remote location.
How Office Visits Are Classified
Healthcare systems classify office visits using administrative and clinical distinctions that affect both scheduling and billing. A primary classification separates patients into two groups: new and established. A patient is considered “new” if they have not received any professional, face-to-face services from the physician or another healthcare professional of the same specialty in the same group practice within the past three years.
An “established” patient is one who has received a professional service within that three-year window. While the distinction is administrative, new patient visits often require the provider to dedicate more time to collecting a comprehensive medical history, which is reflected in coding guidelines.
Office visits are also classified by their purpose: problem-focused or preventative. A problem-focused visit addresses a specific illness, injury, or symptom, such as a sore throat or monitoring a chronic condition. In contrast, a preventative visit, often called an annual physical or wellness exam, focuses on screening, counseling, and maintaining overall health.
Preventative services involve checking general well-being and identifying risk factors before symptoms appear. A single appointment can be billed as both preventative and problem-focused if a condition is evaluated and managed during the same encounter. The provider must document the separate work performed for the problem portion to justify the distinct charges.
The Billing Process and Evaluation Codes
The work performed during an office visit is translated into a billable service using Evaluation and Management (E/M) codes. Non-hospital office visits are reported using Current Procedural Terminology (CPT) codes ranging from 99202 to 99215. Codes 99202 through 99205 are used for new patient visits, while 99212 through 99215 are reserved for established patient visits.
The level of the visit determines the final code selected and the reimbursement rate, based on the complexity of the encounter. Providers determine the appropriate code based on either the total time spent on the date of service or the complexity of the Medical Decision Making (MDM).
The history and physical examination performed are documented as medically appropriate, but they are no longer the sole required components for selecting the code level.
Medical Decision Making (MDM)
Medical Decision Making is a key factor assessed by three elements:
- The number and complexity of the problems addressed.
- The amount and complexity of data reviewed and analyzed.
- The risk of complications or mortality associated with the patient’s management.
For example, a visit addressing an acute, uncomplicated illness would be coded at a lower level than one involving a patient with a severe exacerbation of a chronic condition. Detailed clinical documentation is necessary to support the chosen E/M code, ensuring the record accurately reflects the complexity and intensity of the service provided.
Patient Costs and Insurance Coverage
The cost a patient is responsible for after an office visit is determined by their specific health insurance plan and how the visit was coded. Out-of-pocket expenses for a problem-focused visit typically involve a combination of copayments, deductibles, and coinsurance. A copayment is a fixed dollar amount paid at the time of service, which may vary depending on the type of provider seen.
The deductible is the amount a patient must pay out-of-pocket annually before the health insurance plan begins to cover costs. Once the deductible has been met, coinsurance—a percentage of the total allowed cost for the service—applies until the patient reaches their annual out-of-pocket maximum.
The Affordable Care Act mandates that certain preventative office visits and screenings be covered by most insurance plans with no cost-sharing. For a purely preventative visit, the patient should not owe a copay, deductible, or coinsurance. However, if a problem is addressed during the appointment, the provider must bill for the problem portion separately, which can trigger the patient’s cost-sharing obligation.
After the insurance company processes the claim, the patient receives an Explanation of Benefits (EOB). This statement details how the claim was paid, showing the E/M code used, the total charges, the amount the insurer paid, and the remaining amount the patient owes. Reviewing the EOB helps patients confirm the services rendered and understand their financial responsibility before paying the provider’s bill.