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Here's the latest update on fees and reimbursements in primary care--and the gaps between them.
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Here's the latest update on fees and reimbursements in primary careand the gaps between them.
With relatively few exceptions, reimbursements this year for medical services and procedures are flat or sinking. That's been true for at least five years, according to the latest Medical Economics Continuing Survey, which samples MDs and DOs in office-based private practice.
Once again, third-party payers give physicians less than half their fees for most CPT codes for major procedures and services. For example, cardiologists typically receive $30 of the median $65 they charge for an ECG with interpretation and report.
The decline in reimbursements in the surgical fields continues. Despite relatively modest fee increases, actual reimbursements fell yet again this year for ob/gyns, general surgeons, and orthopedic surgeons.
The news is better for office visits, but not by a lot. While actual payments still lag behind physician fees, there has been some improvement. On average, doctors receive about 75 percent of their actual charges.
General internists raised median initial office visit fees in all five CPT codes by an average of $5.40. Reimbursements were up $3 for 99201 and 99202, but remained the same for more-extensive visits. For established patients, internists raised median fees by $3.20 on average, while actual payments declined by about 40 cents. Median fees for ECGs rose by $5, while reimbursement stayed the same. The pattern was reversed for sigmoidoscopy: Internists raised their median charge by $3, but the median reimbursement climbed by $5.
Family physicians raised median initial office visit fees by $4 on average, while actual payments went up an average of $3. For revisits, fees rose by an average of $4.20, but reimbursement climbed by $3.80. For hospital care, however, FPs raised median fees by almost $6 per code, while reimbursement went up by an average of almost $7.
GPs' initial office visit fees rose in three codes and declined in two, for no change on average. Reimbursement was also unchanged. For revisits, median fees rose $1.80 on average, while actual payment rose by $1.60.
Pediatricians raised median initial office fees by an average of $6, while reimbursement rose $4.20. For established patients, the increases were $5.40 for fees and $4.40 for reimbursements. Median hospital fees rose by $1.67 on average, while reimbursement was $3 higher. Median fees rose 4 percent for three of pediatricians' four major services, but there was little change in reimbursement.
Invasive cardiologists raised median initial office fees by an average of $12.80, while reimbursement rose $6.70. For revisits, median fees increased by $5.60, while actual payment went up $7.25 on average. Noninvasive cardiologists raised median initial office fees by an average of almost $17 per code, but received only $6.50 in additional reimbursement. For revisits, median fees rose by an average of $8.25, while reim- bursements went up only about $3. For six major cardiology services we surveyed, median fees increased by 4 percent, but reimbursements declined or remained the same as last year.
Ob/gyns raised median initial office fees by an average of $8.40, but reimbursement increased $4.40. For revisits, median fees were up $1.40, while actual payments rose by $2. For nine major procedures, median fees rose by an average of 10 percent, while reimbursements declined by 3 percent.
How do your fees and reimbursement levels stack up against the norms set by colleagues in your specialty and size of practice? See the accompanying tables, and commentaries. For a description of how the survey was conducted, see "Earnings: Time to call a code?".
New patient (99204) | Established patient (99213) | |||
Fee | Actual payment | Fee | Actual payment | |
Solo practice | $135 | $91 | $60 | $45 |
2 doctors | 135 | 100 | 62 | 48 |
3 doctors | 150 | 115 | 57 | 47 |
4 doctors | 155 | 110 | 65 | 45 |
5-9 doctors | 140 | 100 | 62 | 47 |
10-24 doctors | 150 | 110 | 60 | 47 |
50 doctors or more | 160 | * | 72 | * |
Doctors in single-specialty groups | 150 | 111 | 63 | 47 |
Doctors in multispecialty groups | 150 | 99 | 62 | 45 |
Doctors in salaried groups | 142 | 100 | 65 | 45 |
New patient | ||||||||||
99201 | 99202 | 99203 | 99204 | 99205 | ||||||
Actual payment | Fee | Actual payment | Fee | Actual payment | Fee | Actual payment | Fee | Actual payment | Fee | |
Cardiologists (invasive) | $69 | * | $90 | * | $125 | $80 | $160 | $100 | $200 | $150 |
Cardiologists (noninvasive) | 65 | * | 100 | * | 128 | * | 180 | 113 | 225 | 150 |
FPs | 50 | $38 | 70 | $56 | 92 | 74 | 125 | 100 | 162 | 120 |
General internists | 59 | 38 | 78 | 55 | 100 | 70 | 140 | 100 | 177 | 125 |
GPs | 50 | 36 | 65 | 50 | 79 | 61 | 100 | 75 | 125 | 95 |
Ob/gyns | 65 | 40 | 85 | 60 | 107 | 72 | 145 | 91 | 170 | 120 |
Pediatricians | 50 | 37 | 70 | 50 | 90 | 66 | 120 | 85 | 150 | 110 |
All respondents | 55 | 38 | 75 | 55 | 100 | 72 | 140 | 100 | 175 | 125 |
Participate with HMOs | 55 | 38 | 77 | 56 | 100 | 70 | 142 | 98 | 175 | 120 |
No participation with HMOs | 50 | 39 | 70 | 58 | 95 | 80 | 132 | 100 | 165 | 137 |
Participate with PPOs | 55 | 38 | 75 | 56 | 100 | 72 | 140 | 98 | 175 | 125 |
No participation with PPOs | 50 | 35 | 70 | 51 | 95 | 76 | 135 | 102 | 165 | 138 |
New patient | ||||||||||
99211 | 99212 | 99213 | 99214 | 99215 | ||||||
Actual payment | Fee | Actual payment | Fee | Actual payment | Fee | Actual payment | Fee | Actual payment | Fee | |
Cardiologists (invasive) | $30 | * | $50 | $34 | $70 | $47 | $90 | $70 | $125 | $99 |
Cardiologists (noninvasive) | * | * | 50 | * | 70 | 45 | 100 | 70 | 140 | 100 |
FPs | 30 | $20 | 45 | 34 | 58 | 45 | 84 | 68 | 120 | 98 |
General internists | 35 | 20 | 48 | 33 | 65 | 46 | 88 | 64 | 125 | 88 |
GPs | 30 | 22 | 40 | 34 | 51 | 43 | 75 | 56 | 100 | 75 |
Ob/gyns | 35 | 25 | 50 | 35 | 70 | 45 | 90 | 64 | 125 | 85 |
Pediatricians | 30 | 21 | 45 | 35 | 60 | 45 | 80 | 60 | 120 | 85 |
All respondents | 32 | 20 | 46 | 34 | 60 | 45 | 85 | 64 | 125 | 90 |
Participate with HMOs | 32 | 20 | 46 | 33 | 62 | 45 | 85 | 63 | 125 | 90 |
No participation with HMOs | 30 | 21 | 45 | 35 | 60 | 46 | 85 | 68 | 124 | 100 |
Participate with PPOs | 32 | 20 | 46 | 34 | 61 | 45 | 85 | 65 | 125 | 90 |
No participation with PPOs | 30 | 23 | 45 | 35 | 55 | 45 | 85 | 65 | 125 | 100 |
% charging it among | |||
Fee | General internists | Cardiologists (invasive) | Cardiologists (noninvasive) |
$80 or more | 17% | 11% | 14% |
75-79 | 7 | 14 | 20 |
65-74 | 20 | 26 | 17 |
60-64 | 9 | 11 | 15 |
55-59 | 7 | 6 | 3 |
50-54 | 21 | 15 | 10 |
40-49 | 12 | 6 | 11 |
30-39 | 2 | 6 | 8 |
Less than $30 | 4 | 4 | 2 |
Median fee (change since 2000) | $60 (+9%) | $65 (+16%) | $65 (+8%) |
Median reimbursement (change since 2000) | 32 (no change) | 29 (3%) | 32 (+7%) |
% charging it among | |||
Fee | General internists | FPs | Gastroenterologists |
$275 or more | 12% | 8% | 12% |
250-274 | 4 | 9 | 12 |
225-249 | 10 | 12 | 8 |
200-224 | 15 | 12 | 18 |
175-199 | 15 | 8 | 15 |
150-174 | 16 | 22 | 18 |
125-149 | 15 | 19 | 7 |
100-124 | 7 | 4 | 6 |
Less than $100 | 7 | 6 | 3 |
Median fee (change since 2000) | $175 (+2%) | $166 (2%) | $200 (+4%) |
Median reimbursement (change since 2000) | 100 (+5%) | __* | 90 (2%) |
Fee | Invasive only |
$700 or more | 13% |
600-699 | 9 |
500-599 | 23 |
400-499 | 16 |
300-399 | 13 |
200-299 | 14 |
Less than $200 | 11 |
Median fee (change since 2000) | $400 (2%) |
Median reimbursement (change since 2000) | 213 (3%) |
Fee | All cardiologists |
$1,000 or more | 9% |
800-999 | 3 |
700-799 | 10 |
600-699 | 15 |
500-599 | 12 |
400-499 | 12 |
300-399 | 12 |
200-299 | 16 |
Less than $200 | 10 |
Median fee (change since 2000) | $500 (no change) |
Median reimbursement (change since 2000) | $150 (25%) |
Fee | All cardiologists |
$600 or more | 8% |
500-599 | 6 |
400-499 | 11 |
300-399 | 16 |
200-299 | 17 |
100-199 | 20 |
100 | 6 |
Less than $100 | 16 |
Median fee (change since 2000) | $200 (no change) |
Median reimbursement (change since 2000) | 45 (no change) |
Fee | Invasive only |
$2,000 or more | 8% |
1,500-1,999 | 6 |
1,200-1,499 | 11 |
1,000-1,199 | 13 |
800-999 | 14 |
600-799 | 11 |
500-599 | 13 |
400-499 | 6 |
300-399 | 10 |
Less than $300 | 7 |
Median fee (change since 2000) | $800 (+6%) |
Median reimbursement (change since 2000) | 300 (-3%) |
Fee | Invasive only |
$600 or more | 7% |
500-599 | 18 |
400-499 | 5 |
300-399 | 13 |
250-299 | 7 |
200-249 | 10 |
150-199 | 16 |
100-149 | 13 |
Less than $100 | 10 |
Median fee (change since 2000) | $250 (no change) |
Median reimbursement (change since 2000) | * |
Hospital care, initial | ||||||
99221 | 99222 | 99223 | ||||
Fee | Actual payment | Fee | Actual payment | Fee | Actual payment | |
FPs | $106 | $79 | $143 | $113 | $181 | $150 |
Gastroenterologists | 115 | 75 | 155 | 110 | 200 | 145 |
General internists | 120 | 73 | 155 | 110 | 200 | 142 |
GPs | 96 | 64 | 122 | 96 | 150 | 120 |
Hospital care, subsequent | ||||||
99231 | 99232 | 99233 | ||||
Fee | Actual payment | Fee | Actual payment | Fee | Actual payment | |
FPs | $60 | $42 | $80 | $60 | $105 | $85 |
Gastroenterologists | 60 | 38 | 75 | 50 | 100 | 75 |
General internists | 60 | 40 | 80 | 56 | 106 | 77 |
GPs | 50 | 40 | 65 | 54 | 80 | * |
Pediatricians | 60 | 43 | 82 | 60 | 113 | 80 |
Doctors in the West charge the most for new-patient office visits. Their Midwestern colleagues typically charge $15 less, but receive the most in actual payments. For revisits, Western doctors have the highest reimbursements.
New patient (99204) | East | Midwest | South | West | ||||
Fee | Actual payment | Fee | Actual payment | Fee | Actual payment | Fee | Actual payment | |
FPs | * | * | $125 | $107 | $125 | $98 | $140 | * |
General internists | $150 | $95 | * | * | 130 | 100 | 160 | * |
Ob/gyns | * | * | 135 | * | 138 | 95 | * | * |
Pediatricians | 100 | 80 | * | * | 120 | 87 | 141 | * |
All respondents | 145 | 90 | 135 | 105 | 133 | 98 | 150 | 100 |
Participate with HMOs
140 | 86 | 135 | 105 |
140
98 | 150 | 100 |
No participation with HMOs
150 | * | 127 | 113 | 125 | 100 | 155 | 100 |
Participate with PPOs
140 | 90 | 135 | 105 | 135 | 98 | 150 | 104 |
No participation with PPOs
145 | 82 | 125 | * | 125 | 100 | 165 | * |
New patient (99213) | East | Midwest | South | West | ||||
Fee | Actual payment | Fee | Actual payment | Fee | Actual payment | Fee | Actual payment | |
FPs | $65 | * | $56 | $45 | $57 | $45 | $60 | * |
General internists | 65 | 47 | * | * | 63 | 45 | 65 | * |
Ob/gyns | * | * | 70 | 48 | 70 | 45 | * | * |
Pediatricians | 60 | 45 | 60 | * | 57 | 45 | 60 | * |
All respondents | 65 | 45 | 59 | 45 | 60 | 45 | 65 | 47 |
Participate with HMOs
65 | 45 | 60 | 45 | 63 | 45 | 64 | 45 |
No participation with HMOs
75 | * | 55 | 44 | 56 | 45 | 65 | 50 |
Participate with PPOs
65 | 45 | 60 | 45 | 60 | 45 | 65 | 45 |
No participation with PPOs
70 | 47 | 50 | * | 50 | 45 | 70 | * |
All respondents | New patient (99204) | Established patient (99213) | ||
Fee | Actual payment | Fee | Actual payment | |
Inner city | $127 | $80 | $65 | $40 |
Urban | 150 | 100 | 65 | 45 |
Suburban | 145 | 100 | 64 | 46 |
Rural | 125 | 100 | 55 | 45 |
Fee (change since 2000) | Actual payment (change since 2000) | |
Upper gastrointestinal endoscopy, diagnostic (43235) | $500 (+1%) | $220 (no change) |
Liver biopsy, needle; percutaneous (47000 | 300 (+9%) | 150 (+15%) |
Dilation of esophagus, by unguided sound or bougie, single or multiple passes (43450 | 200 (no change) | 100 (+11%) |
Appendectomy (44950) | $1,200 (no change) | $569 (-5%) |
Laparoscopy, surgical; appendectomy (44970) | 1,415 (+3%) | 600 (-1%) |
Cholecystectomy (47600) | 1,900 (+3%) | 800 (no change) |
Laparoscopy, surgical; cholecystectomy (47562) | 2,330 (no change) | 850 (no change) |
Initial inguinal hernia repair, age 5 or over; reducible (49505) | 1,118 (-4%) | 475 (-6%) |
Gastrectomy/partial, distal with gastroduodenostomy (43631) | 2,500 (no change) | 1,100 (-8%) |
Modified radical mastectomy (19240) | 2,200 (-3%) | 1,000 (no change) |
Excision of cyst or fibroadenoma from breast tissue, one or more lesions (19120) | 721 (+3%) | 350 (-7%) |
Circumcision, clamp, newborn (54150)
$100 (no change)
Total hysterectomy, abdominal (58150) | 2,600 (+4%) | 1,200 (-8%) |
Complete OB care, routine, vaginal delivery (59400) | 2,500 (+4%) | 1,700 (+6%) |
Complete OB care, routine, with cesarean section (59510) | 2,875 (+3%) | 1,800 (no change) |
Dilation and curettage, diagnostic and/or therapeutic (nonobstetrical) (58120) | 682 (no change) | 285 (-5%) |
Dilation and curettage, for induced abortion (59840) | 750 (+15%) | 350 (no change) |
Dilation and evacuation for induced abortion (59841) | 807 (+8%) | __ |
Laparoscopy, surgical, with fulguration of oviducts (58670) | 1,240 (+3%) | 570 (-5%) |
Colposcopy (vaginoscopy);LEEP (57460) | 650 (+24%) | 260 (-11%) |
Colles fracture, closed manipulation (25605) | $750 (+11%) | $400 (no change) |
Open treatment of hip fracture (27244) | 2,750 (+5%) | 1,206 (+1%) |
Knee arthroscopy with meniscectomy (29881) | 2,250 (+6%) | 835 (-7%) |
Total hip arthroplasty (27130) | 4,560 (+1%) | 1,700 (-6%) |
Diagnostic knee arthroscopy (29870) | 1,065 (+7%) | 474 (-5%) |
Total knee arthroplasty (27447) | 4,848 (+8%) | 1,800 (-4%) |
Arthrocentesis of knee (20610 | 100 (+11%) | 65 (+16%) |
History and examination of normal newborn (99431) | $145 (+7%) | $100 (+2%) |
Immunization, DTaP (90700) | 35 | 23 |
MMR virus vaccine, live (90707) | 50 (no change) | 36 (-3%) |
Circumcision, clamp, newborn (54150) | 150 (+6%) | 100 (+5%) |
Mark Crane. Survey Report: What you charge vs what you get.
Medical Economics
2001;20.