Patient Cost Examples

Please refer to the Glossary for more information on terms and abbreviations.

Evaluation and management (office visits)

Patient 1, whose primary insurance is Medicare, presents for follow up of high blood pressure and is stable on a multiple drug regimen. Based on the provider's documentation, the charge is coded as 99213, evaluation and management of an established patient.

As a Medicare patient, this charge may be billed with professional PRO and facility FAC components. These charges will be on separate bills and may be sent to Medicare on different days.

PRO $158 + FAC $66 = Global $224

Patient 2 who has commercial insurance (such as Quartz, BCBS, WEA, etc.) presents for follow up of known osteoarthritis and painful swollen knees. Based on the provider's documentation, the charge is coded as 99213, evaluation and management of an established patient.

As a patient with commercial insurance, this charge will be billed with a global fee of $244 on one bill.

Imaging Services

Patient presents for a two-view chest X-ray. As a service requiring professional interpretation, the charge will be billed in two components using modifier TC for the facility portion and modifier 26 for the professional interpretation.

Mod TC@$253 + Mod 26@$70 = Global $323

Note: This may be billed on one line as one charge if a specific payer requires that format.

Surgical procedures

Note: This is an example, not an estimate. Because multiple charges, both professional and facility, may be billed for a surgical procedure, it is highly recommended that an estimate be obtained prior to any surgery.  

Patient presents for total hip replacement (arthroplasty). The surgery takes 90 minutes. Professional surgical, professional anesthesia, facility anesthesia, operating room and recovery room charges may be billed.

The surgeon's fee is separately billable based on CPT code.

Professional anesthesiologist charges are base units plus additional units for each additional 15 minutes of anesthesia time. In this example, the base time of 1 hour plus an additional 30 minutes will be billed.

• 8 base units + 6 units for each 15-minute increment = 14 units
• 14 units X $180/unit = $2,520

Facility anesthesia charges are for a base rate plus additional increments based on time. Time calculation may be based on single minute,15 minutes, 30 minutes or 60 minutes based on hospital location.

In this La Crosse example, if the surgery took 90 minutes:

• Base charge $1579 for first hour + 30 additional minutes at $26 each = $2,359

Operating room charges are for a base rate plus additional increments based on time as with facility anesthesia. In this La Crosse example, if the surgery took 90 minutes:

• Base charge $5565 for first hour + 30 additional minutes at $100 each = $8,565

Recovery room charges are for a base rate plus additional increments based on time as with facility anesthesia. In this La Crosse example, if the recovery time was 70 minutes:

• Base charge $1823 for first hour + 10 additional minutes at $30 each = $2,123