Dear Families,
We’d like to address questions we have had surrounding well visits where an additional charge has been added when a physician addresses a health issue during the well visit.
A patient may receive separate charges for a well visit and an ill visit if a "significant, separately identifiable" medical problem is addressed during a scheduled preventive visit. The well portion of the visit is billed as preventive care, while the ill portion is billed as a problem-focused visit. This is a standard insurance requirement and is not a billing error.
Your recent appointment may have been billed as two separate services because, in addition to your annual wellness exam, your child also had a significant, separately identifiable medical problem addressed during the same visit.
The wellness visit covers routine check-up items, such as a physical exam, updating your health history, and screening for common health concerns. For most plans, this service is covered with no out-of-pocket cost.
The sick visit charge is for the diagnosis and management of a specific health issue. When this is treated at the same visit as your wellness exam, insurance rules require us to bill for it separately. This is a distinct service that often involves its own copay, coinsurance, or deductible.
Chronic health issues in children that may prompt a separate follow-up visit during a well-child visit include asthma, ADHD, obesity, allergies, eczema, sleep disorders, developmental concerns, and behavioral or mood disorders. These issues may be identified during routine screenings and often require more resources, time and/or documentation than a standard wellness visit.
Insurance companies require the clinic to bill for the two different types of services separately.
Often, the health issue is tied to the child’s overall well-being and should not wait. Rather than ask parents to make an additional appointment, the family receives two separate services in a single, convenient trip to the clinic. This combination saves them from making and paying for another appointment later.
The clinic is following standard coding and billing rules. Privia’s certified coders will add CPT modifier 25 to communicate this to payers when a combined charge is appropriate and there is documented support.
Pediatric Associates Inc/ Privia Medical Group
Dear Established Patient, You might be curious about the online forms we're asking you to complete, especially if you've provided this information before. Pediatric Associates Inc has recently transitioned to a new electronic health records system. If your child's last appointment was before May 13th, 2025, we kindly request you to update your information in our new system. This may include demographic details, insurance information, consent for treatment and for others to bring your child to appointments, as well as financial responsibility. We will also need an updated health history. The good news is that we will only ask for these updates once a year unless you have experienced a change! Depending on the type of visit, we also utilize several important screeners. For physical exams, these help us monitor your child's overall health, wellness, and development. If your child is coming in for a medication or chronic condition follow-up, these screeners assist us in evaluating the effectiveness of their current treatment plan. Additionally, we can provide resources for certain social needs if necessary. All completed screeners are automatically scored and integrated into your child's chart, allowing our team to ensure they receive the best possible care. You will receive a registration link via Phreesia one to two days before your scheduled appointment. Please complete these forms prior to your visit to allow your physician adequate time to review them. Thank you for your cooperation as we implement this new system to better serve our patients. Sincerely, Teri L. Persinger Executive Director
