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Connect Your MedicareDr. Sarah Johnson, MD
Financial Breakdown
Coverage Details
This service is covered under your insurance plan. No deductible was applied to this claim. Medicare Coinsurance of $19.20 applies.
Cost Breakdown
Coverage Insights
- Preventive visit (G0438) allowed at 100% of fee schedule
- Standard office visit (99213) subject to Part B deductible and coinsurance
💡 These insights are derived from Medicare's adjudication data to help explain your coverage details.
AI Summary
This was a routine office visit with Dr. Sarah Johnson for a general adult medical examination. While the claim was processed and approved, our AI analysis identified a potential billing inconsistency. The visit was billed as a diagnostic office visit (99213) in addition to an annual wellness visit (G0438). Typically, if the primary purpose is preventive, the diagnostic code should not be applied unless a separate, significant medical issue was addressed. This has resulted in a $19.20 coinsurance charge that may be contestable.
Risk Flags
- •Potential unbundling of services (99213 with G0438)
- •Modifier 25 missing or incorrectly applied
- •High likelihood of success for appealing 99213 coinsurance
Insights
- •Diagnostic services during wellness visits are subject to cost-sharing
- •Appeal coinsurance for code 99213 if no separate medical issue was treated
Tags
General adult medical exam
Encounter for general adult medical examination without abnormal findings. This code is used for routine health check-ups where no specific complaint or illness is being addressed.
Present on admission: No
Office/outpatient visit for the evaluation and management of an established patient
Office visit, established patient, low-moderate complexity
Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. Typically involves 20-29 minutes of total time.
Annual wellness visit; includes a personalized prevention plan of service (pps), initial visit
Annual wellness visit, initial
Annual wellness visit, including a personalized prevention plan of service (PPS), initial visit. This service is for patients who have been enrolled in Medicare Part B for more than 12 months.
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