The Principles of Billing
Case Study
 Dr. New Entrant (NE) completes his/her FM residency
in 5 months. To date, she only fills in a patient
encounter form which the unit manager will use to do
the billing. Her preceptor is on salary with the
teaching program funded by a ARP. There has been
no specific instruction in billing. The program
encourages the resident to learn this during their
community rotations. NE doesn’t know how to bill or
how to obtain her billing #.
Introduction
 Most physicians are self-employed vs salaried
 As a professional, you provide a service
 Your income is received upon billing and receipt of
payment for services rendered
 You are now a proprietor in the Service Industry
called Medicine
Areas to be Addressed
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Registering with the provincial HCP
When, how and who to bill
Staff Training
Where to go for Help
Monitoring
The components of a bill to provincial Health Care
Plans (HCP) or WCB
 The “bread & butter” of billing
Areas to be Addressed (cont’d)
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Third Party Billing
Uninsured/Noninsured Services
Alternate Billing Options
NEVER FORGET TO....!!
Common Mistakes
Registering with Your HCP
 Provincial registration variations & exclusion criteria
 Contact provincial licensing college
 application for Independent Practice License
 Contact HCP for “Application for Billing Number”
 Billing # restrictions may apply!
 Register with WCB
Choosing a Billing Package
 List of approved submitters
 310-000 (780) 422-0069
 AMA Web site (www.albertadoctors.org)
 computerized office
 Physician office system program
 3 approved vendors (Med Access, Telus Health
Solutions (Practice Solutions), Telus Health Solutions Wolf Medical System)
 Practitioners in Similar practices
 Service Bureau’s VS Direct Submission
 Cost, support, availability of software
HCP Physician Information Kit
 HCP Schedule of Benefits (www. albertadoctors.org, fees and
negotiation, billing advice)
 General Rules
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Procedure list
Fee modifier list
Price list
Explanatory codes
 Diagnostic code manual
 AHW Web site (http://www.health.alberta.ca/documents/Diagnostic-CodeICD-9.pdf
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A Physicians Resource Guide /AH&W Bulletins
 AHW Web site (http://www.health.alberta.ca/documents/PhysicianResource-Guide-2014.pdf)
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Facility Listing
 AH Web site (http://www.health.alberta.ca/documents/Facility-Listing2014-04.pdf)
Staff Training
 Office policies
 Billing for Uninsured services
 Alberta Health Billing
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Submission
Reconciliation
Resubmission
Not all services are billable - varies from province to
province
 Supervised services
 Reciprocal Billing
Where to go for Help
 Physician Resource Guide
 Alberta Health
 310-0000
(780) 427-1432
 AMA - Physician Advocacy
 1-800-272-9680 (780) 482-2626
 e-mail
marilyn.kroon@albertadoctors.org
darcy.shade@albertadoctors.org
marisa.bonuccelli@albertadoctors.org
billingadvice@albertadoctors.org
Verifying AH Coverage
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IVR 1-888-422-6257
Netcare
Opted out
Good Faith Claims
Invalid AHC Numbers
 Office
 Bill patient
 Hospital Patient
 Name, address, phone number, ULI, DOS,
DOB, claim number
Remittance Review & Reconciliation
 The weekly process of reviewing if you have
received 100% payment for the services you have
rendered to date
 Unpaid or partially paid accounts should be
reviewed, corrected & resubmitted to the
responsible party
Monitoring
 Verify assessment results
 Is explanatory code acceptable
 Paid does not equate to assessment is correct
 Few edits in place
 Physicians responsibility to ensure that assessment is
correct
Responsible Party
 The Responsible Party remits payment to the
physician for services rendered
 Provincial HCP
 WCB
 Third parties (uninsured services)
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insurance companies
employers
lawyers
government agency
 Patient (insured or uninsured)
Worker’s Compensation
 Obtaining a Registration (billing) number
 Edmonton 780 498-4316 or toll free 1-866-922-9221
 Always verify if the patient is covered by WCB
when assessing all work related medical
complaints.
 Knowingly billing the Provincial HCP for WCB
services is…fraudulent
 WCB pays for form completion
 Claims submission must be electronic
Reciprocal Billing
 All provinces & territories, except Quebec, have
mutual arrangements that allow the physician to bill
the patient’s “home province” for services
rendered
 Payment is rendered at the rates of the “host
province”
 Some exceptions/exclusions
 Physician’s Resource Guide (section 4)
Billing Period
 AHW provides weekly payments
 Accounts receivable = 2 - 4 weeks
 AHW claim submission deadlines are 180 days
from service date or 180 from last communication
 Note AH has indicated to AMA they want to move to 90
days.
The Components of a Bill
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Service provider PRACID
Skill Code
Recipient ULI
Date of service
Location of service
Referral PRACID if
applicable
 Health service code
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Calls
Diagnostic code
Encounter number
Modifiers if applicable
Facility number
Functional centre
Responsible party
Recovery code
Billing Documentation
 Billing Day sheet
 Computer record
 Patient record must be able to stand alone as an
indicator of what services and procedures were
provided without your interpretation!!!
 AHC legislation
 Records must be kept minimum of 6 years
Know Your Fee Schedule
 Provincial HCP’s “Schedule of Benefits” dictate the
fees you receive
 Fees change - READ ALL BULLETINS
 Stay up-to-date
 Request new SOMB fax (780) 427-1093
 http://www.health.alberta.ca/professionals/SOMB.html
 Review the schedule - general rules, procedure list and
associated notes, modifiers
 PHYSICIAN DECIDES ON CODE TO SUBMIT
 IGNORANCE leads to LOST INCOME
The “Bread & Butter” of Billing
 In general, most specialties use 5-6 service codes
more often than any others
 Learn what criteria must be met before using these
codes
 Each code is explained in the procedure list of the
HCP “Schedule of Medical Benefits”
Bread and Butter Codes:
03.03A
Limited visit not requiring complete
history and evaluation
$35.92
-75 years and older 03.03A + 20%
03.03B Prenatal visit
$35.78
03.04A Comprehensive visit
$98.78
CMGP01 - 10
Complex patient visit modifier/unit $15.56
- 03.01J, 03.03A, 03.03B, 03.03C, 03.03N, 03.03P,
03.03Q, 03.07A, 03.07B
Bread and Butter Codes cont’d:
CMXC30 Complex visit/consultation modifier $30.56
- 03.04A, 03.04B, 03.04C, 03.04D 03.04M, 03.08A
08.19G Direct contact with a patient for
psychiatric treatment, per 15 minute $44.90
98.12A Excisional biopsy, skin
$41.25
03.04M Pre op history & physical
$98.78
Comprehensive care plan
03.04JDevelopment, documentation & administration
of a comprehensive annual care plan for patient
with complex needs
$215.52
- Family physician most responsible
- One/patient/year with ongoing communication
- Not payable within 345 days of previous 03.04J
- May be claimed in addition to 03.03A, 03.03N, 03.04A
- Complex – patient with multiple complex health needs
including chronic disease and other complications
- Two or more diagnosis from group A & B
Comprehensive care plan cont’d
Group A
- Hypertensive disease (401)
- Diabetes Mellitus (250)
- COPD (496)
- Asthma 493)
- Heart Failure (428)
- Ischemic Heart Disease (413 - 414)
- Chronic renal failure (585)
- (2 different GFR readings, >3 mon apart. Values 60-89 must
be accompanied by urine or imaging abnormalities)
Group B
- Mental Health Issues (290 – 319)
- Obesity (Adult + BMI 35, Child = BMI 97 percentile) (278)
- Addictions (303 – 304)
- Tobacco (305.1)
Comprehensive care plan cont’d
Care plan includes:
- Direct contact with patient
- Clearly defined goals
- Detailed review of chart, current therapies and problem list
- Demographic information that may affect patient health &/or
treatment
- Incorporate patient values and personal goals
- Expected outcome
- Identification of other health care professionals that may be
involved
- Physician & patient sign and each keep copy
Most Common Rejected Claims
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Patient coverage problems
Duplicate services
Patient seen twice in one day
Missing information on claim
Reductions by the Ministry
What does this cost you every Month/Year?????
Primary Care Networks
 Objectives of PCN include
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Increase access to primary care
Manage 24/7 access to appropriate care
Increase emphasis on promotion and prevention
Greater use of multi-disciplinary teams
Better coordination and integration between the
components of the health system
Primary Care Initiative cont’d
 Local Primary Care Networks (LPCN)
 Arrangement between group(s) and a regional health
authority (shared leadership)
 Local flexibility to address local needs
 Manages the comprehensive care of a population
 Patient population defined through formal or informal
enrolment
 Funding follows the patient
AMA Practice Management Program
To provide high quality change management
products and services primarily to physicians
entering Local Primary care Networks (LPCN’s)
Third-Party Billing & Uninsured
Services
 Services not covered by provincial HCP or WCB
 Physician bills the responsible party (insurance
company, employer, lawyer, government agency or
directly to the patient)
 Not subject to clawbacks
Non-insured Services
Why Physicians Don’t Bill
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It will create public relations problems
It will create administrative problems
It’s not financially worth it
I’ve never done it before
I don’t want to be the first in town to do it
I don’t know how
My patient’s won’t like me.
Is Bill a 4-letter word?
What will really happen
 My patients will recognize that ALL my time is
valuable
 I will accept that ALL my time is valuable
 I will get paid for things that I now do for free
 My revenues will increase
 Overhead ratio will decrease
 My practice remains viable
 Able to take time off
Billing for Un-insured Services is...
EXTREMELY IMPORTANT
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Be proactive - start from day one!
Be consistent
Use discretion
Inform patients of their responsibility for payment
prior to the delivery of the service
 Don’t feel guilty for billing appropriately for
uninsured services
Common Uninsured Services
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Sick notes and medical certificates
Employment insurance forms
Phone call prescription renewals
Chart transfer charges
Missed appointments
Insurance reports
Cosmetic procedures
Uninsured Service Fees
 Most provincial medical associations provide
recommended rates for uninsured services
 Contact your provincial medical association for
more information
Alberta Medical Association
Recommended Fees
 Medical - legal services
 Report on patient attended
 Review & interpretation of file
 Phone Rx renewal
 Sick note - note only
- exam & note
$500 - 700/hr
$450 – 625/hr
$55 -75
$50
$90 - 135
Alberta Medical Association
Recommended Fees
 Driver’s Exam (<74.5 years) form only
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Exam and form
 EI / Maternity
 CPP Disability
 short narrative, 1 page (15 – 20 min)
 full narrative, 2 pages (40 – 45 min)
 Detailed narrative, 3 or more pages (60 min)
$75 – 150
$150 -275
$55 - 95
$50
$100
$150
 Insurance Disability
 Form completion only
 Examination & form
 Chart Transfer patient request
 + photocopying $0.25/page (HIA)
$60 - 125
$145 - 230
$25
Remember!
 Billing for 1 sick note at $50 for every office day
generates ~ $14,000/year... office medical supplies
cost < $3,000 per year
 Can you afford not to bill for these services?
 If you undervalue your services, so will your
patients
Commonly Missed Services
 Palliative care (03.05I)
 Unrelated AHC service with WCB (03.01J)
 Visit with non surgical treatment of warts
(98.12L)
 Visit with IUD insertion (81.8)/removal (11.71A)
 CMGP modifier (03.01J, 03.03A, 03.03B,
03.03C, 03.03N, 03.03P, 03.03Q, 03.07A)
 CMXC30 modifier (03.04A, 03.04B, 03.04C,
03.04D, 03.04M)
 Complex inpatient modifier (COINPT) (03.03D,
03.03AR)
 03.01AATime premium
Commonly Missed services
 Telephone advice (03.01B, BA, BB;
03.01NG, NH, NI, 03.01LM, LN, LO,
03.01NM)
 Physician to physician advice (03.01LG, LH,
LI, LJ, LK, LL)
 Periodic Pap smear (13.99BA)
 INR Management (03.01N)
 REVIEW ALL premiums and modifier codes
in Schedule of Fees
NEVER FORGET TO !!!!!!!!
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Complete all components of the bill!
Always verify who is the responsible party!
Bill for daily minor procedures
Bill WCB whenever appropriate
NEVER FORGET TO !!!!!!!
 Stay up-to-date with the fee schedule
 Never bill the HCP for uninsured services
 Bill for uninsured services when appropriate
Common AHC Billing
Examples
Introduction
 The key billing components billed to the Ministry of
Health are:
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health service codes
diagnostic codes
modifiers
physician and patient identification
 Code definitions and #’s vary by province
Billing Examples: Alberta 2011
 Q1. A thorough office visit for a URI with an IM (flu)
shot given?
 03.03A
465.9
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Possible CMGP01 (modifier )
 13.59A
V04.8
$35.92
$15.56
$9.58
($45.50 if modifier not applicable or $61.06 if applicable)
 Q2. Complete office assessment of 85 year old for
chest pain, urinalysis done?
 03.04A
786.5
 Possible CMXC30 (modifier)
$98.78
$30.56
Billing Examples
 Q3. Office visit for BP follow-up?
 03.02A
401.9
$20.94
 Q4. 25 minutes assessing an anxious patient?
 03.03A CMGP02 300
or
 2 - 08.19G
(35.92+15.56+15.56)
$67.04
300
$89.80
(44.90 x 2)
Billing Examples
 Q5. Complete assessment 74 year old febrile male one week
post-operative discharge.
 03.04A
780
$98.78
Note: CMXC30 may be applicable if 30 minutes spent adds an
additional $30.56
 Q6. Detailed office assessment, suspected ulcerative colitis,
flexible sigmoidoscopy?
 03.03A
 01.24B (+ tray)
556
556 (74.92 +37.71)
$ 35.92
$112.63
($148.55)
Billing Examples
 Q7. Emergency house call, 3pm,weekday, first
patient seen, breast cancer, 25 minutes?
 03.03N CMGP02 174 (79.35 + 31.12)
or
 03.05I x 2
174
$ 110.47
$98.18
 Q8. Same visit, spouse seen and NSAIDs reordered for osteoarthritis?
 03.03P
715
Possibly CMGP01 (if 15 minutes spent)
$ 29.93
$15.56
Billing Examples
 Q9. Weekday evening (2100 H) ER visit, complete
assessment, 55 year old, chest pain NYD?
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03.03LA
786.5
03.04A
786.5
Possible CMXC30 (modifier)
03.01AA TEV 02
$107.76
$ 98.78
$ 30.56
$ 43.66
($250.20 if no modifier $280.76 if modifier applicable)
Billing Examples
 Q10. You do a delivery at 1 AM having augmented
the patient. You do post-natal care visits in the
hospital?
 87.98A NTAM
 03.01AA TNTA03
650
(431.74 + 114.17)
(43.65x 3)
$545.91
$130.95
($676.86)
Billing Examples
 Q11. New-born care in hospital, circumcision?
 03.05G (first day)
V30.0
 03.05GA (subsequent days/day)
 In Alberta, the circumcision is uninsured.
$ 70.33
$ 40.58
Billing Examples
 Q12. Evening admission on 2/11/10 at 2330, 72 year
old, Dx CHF, 5 regular hospital visits, special evening
(2100) special callback Sat 6/11/10 to reassess
dyspnea.
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03.04C HANTPM
428 (122.72 + 142.88)
03.01AA TNTP02
(21.83 x 2)
03.03D x 5
428 (40.58 x 5)
03.05R (2100)
428
03.03DF
428
03.01AA TWK01
Use encounter 2 for Sat. callback
$265.60
$ 43.66
$202.90
$ 107.76
$ 40.58
$ 21.83
($682.33)
Billing Examples
 Q13. Office visit, shave biopsy / desiccation of basal
cell Ca < 1 cm, on the face?
 03.03A
 98.81B
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173
173
(Punch biopsy)
Note: 98.81B does not have a tray fee
$35.92
$29.60
($65.52)
Billing Examples
 Q14. Office visit, patient concerned regarding a
changing mole, excisional biopsy.
 98.12M (+ tray)
216.8 (34.23 + 37.71)
(Removal of pigmented benign nevus)
or
If unsure and decide to do excisional biopsy
 98.12A (+ tray)
(41.25 +37.71)
 03.03A
 Should this billing be put on hold?
$71.94
$78.96
$35.92
($114.88)
Billing Examples
 Q15. A patient presents with a plantar wart and
liquid nitrogen is applied?
 98.12L
 03.03A
078.1
078.1
$20.45
$ 35.92
($56.37)
 Don’t forget to bill the patient for the N2
 Q16. A patient requests a visit for N2 treatment of a
wart on their finger
 Can you bill the HCP for this?
 What should you bill?
Billing Examples
 Q17. Regular visit, diabetes and BP assessment,
unanticipated crisis supportive psychotherapy for
additional 22 minutes, marital strife?
 03.03A CMGP02 250
(35.92 + 31.12)
$ 67.04
or
 08.19G x2
300
$89.80
Note: Assessment must have determined that patient is
suffering from a psychiatric disorder
Billing Examples
 Q18. Attendance at labour, assistance at C.S.
which took 1 hour, finished at 10 pm?
 87.98B EV
 86.9C SA
 03.01AA TEV08
656.3
(428.04 + 47.59)
$475.63
$143.95
$174.64
($794.22)
 Q19. Assisting at elective hernia repair, 1 hour
time, 10 am?
 65.01A SA
$143.95
Billing Examples
 Q20. Dr. on duty in ER, multiple systems assessment,
1 am, abdominal pain, NYD?
03.05ER CMXV20 789.0 (28.43 + 15.27)
03.01AA TNTA02
$43.70
$87.30
($131.00)
or
03.04H
789.0
Possibility CMXC30 modifier (30.56)
($126.99 if modifier applicable)
 03.01AA TNTA02
$ 96.43
$87.30
($183.73)
Billing Examples
 Q21. Regular registered nursing home visit to
assess a patient with dementia.
 03.03E
290
$ 26.94
Billing Examples
 Q22. During a periodic health exam you order a
lipid profile. The patient’s lab has returned and is
abnormal. You request a follow-up visit and spend
25 minutes educating the patient regarding their
risk of ASHD and the treatment options for their
abnormal lipid profile.
 O3.03A CMGP02
272 (35.92+ 31.12)
$ 67.04
Billing Examples
 Q23. A postmenopausal woman who has been on
continuous HRT for 4 years presents with
breakthrough bleeding. You do an endometrial
aspirate biopsy.
 03.03A
 80.83B (+tray)
627.1
627.1(42.42 + 12.74)
$35.92
$55.16
($91.08)
Billing Examples
 Q24. A 44 year old male presents with a painful
2cm boil in the left axilla which you incise and
drain.
 98.03A (+tray)
680.8 (31.36 + 12.74) $44.10
(I & D subcutaneous abscess )
 03.03A
680.8
$35.92
($80.02)
Billing Examples
 Q25. A patient receives their regular allergy shot
from the nurse.
 13.42A V07.1
 (Allergy injection)
$10.99
Billing Examples
 Q26. A 35 year female patient presents with a newly
discovered breast lump. You do an appropriate exam
and aspirate 3cc of clear fluid that is sent off for
cytology.
 03.03A
610.0
$35.92
 97.81 (+tray)
610.0 (43.32 + 12.74)
$56.06
(Needle biopsy breast)
 How will bill differ if needle biopsy?
 No difference as above
($91.98)
Billing Examples
 Q27. A patient with tennis elbow unresponsive to NSAIDS and
physiotherapy is seen for follow-up and you decide to inject
with cortisone.
 03.03A
727
$35.92
 95.96A ( for tray)
727
$12.74
($48.66)
Note 95.96A does not allow for visit in addition but need to bill to get
the tray fee
(95.96A rate = $12.57)
(Who pays for the cortisone?)
 Patient is billed ~$10-15 separately
Billing Examples
 Q28. You receive the bi-weekly INR results of a
patient and instruct your nurse to call the patient to
modify their coumadin dosage.
 Can you bill for phone call advice?
 03.01N
$16.46
 Management of anticoagulant therapy, two per
month per patient
Billing Examples
 Q29. A patient has seen you before and decides to
return for the elective removal of a sebaceous cyst.
 Is this an insured service?
 98.12C (+tray)
706.2 (52.35 + 37.71) $90.06
(Removal of sebaceous cyst)
 03.03A
706.2
$ 35.92
($125.98)
Billing Examples
 Q30. A disabled hemiplegic patient with multiple
concerns is seen in follow-up. You also complete a
Disability benefit report for an Insurance company
on their request.
 03.03A 342.9
$35.92
CMGP01 if 15 m excluding report
$15.56
 Disability report - initial medical report &/or
Reassessment medical report
$60 - 125
(patient responsibility)
Billing Examples
 Q31.You have a flu shot clinic where 20 patients
see your nurse for a flu shot.
 13.59A
V04.8
$9.58
 (Note to bill this a physician must supervise)
 Total
20 patients
$191.60
Third Party Billing
Billing WCB
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Verify if work related problem
Verify if patient is covered
Bill WCB for professional service & form completion
It is fraudulent to bill AHW for WCB service
WCB Billing Examples
 33 year old typist with evidence of lateral epicondylitis from
RSI.
 03.03A CMGP01 (35.92 + 15.56)
 Initial report, (C050) (electronic)
 BCP 01/02 X2
$51.48
$58.07
 BCP01 All of Alberta except Calgary & Airdrie $2.82/unit
 BCP02 Calgary & Airdrie
$3.33/unit
WCB Billing Example
 Follow-up visit in 4 weeks, patient has form to fill in,
steroid injection indicated
 0303A
• 95.96A
• MINT (tray)
$35.92
$12.57
$12.74
($61.23)
 Progress report (C051)
 BCP 01/02 x 1
$35.28
WCB Billing Examples
 WCB requests a detailed report and copies of all
consults, exams, investigations.
 Summary of medical information, without opinion
requested by WCB (RF05):
 First 30 minutes
 Additional 15 minute increments
 Photocopying (RF08)
$127.01
$49.41
$0.43 per page
Canada Pension Plan - CPP
 56 year old with severe RA applying for CPP brings
in forms. You later spend 40 minutes preparing a 2
page medical summary. What should you bill
CPP?
 Form / report completion
$100
 What are the CPP billing criteria?
 Based on time spent
CPP Billing Guidelines
 Photocopied info and / or short report
 time spent < 15 minutes
$25
 Chart Review & Short typed narrative report 1-2
pages
 time spent 15-20 minutes
$50
 Full typed narrative, 2 or more pages
 time spent 40-45 minutes
$100
 Detailed typed narrative, 3 or more pages
 time spent 60 minutes
$150
Non-insured Billing
 33 year old seen for tonsilitis & requests sick note
for 2 days
 03.03A (AHW)
 Form completion
$35.92
$50
 Pilot seen for MOT exam
 Examination & form completion
$260 - 450
Non-insured Billing
 14 year old seen for camp physical with form
completion
 Form only
 Examination and form
$50
$130
 22 year old requests N2 for wart on hand
 Non surgical treatment
 Surgical removal
$55 - 100
$95 – 210
Non-insured billing
 Phone request for prescription renewal
 $55 - 75
 Request for removal of 7 skin tags
 individually set
 Travel advice and Hepatitis A shot
 individually set
Medical Legal Reports
 1.5 hours for chart review, report dictation and
review, inclusion of 20 photocopies from chart
 Report
 Photocopies
(HIA)
$450 – 625/hour
$25
 Completion of Insurance Company Medical
summary
 Report & examination
$260 - $450