Annual physical billed as a sick visit

What this looks like in practice

Section 2713 of the ACA (codified at 42 USC §300gg-13) requires non-grandfathered group and individual health plans to cover specified preventive services without cost-sharing when delivered by in-network providers. The list comes from the USPSTF, the CDC Advisory Committee on Immunization Practices, and HRSA — annual physicals, screening colonoscopies, mammograms, well-child visits, immunizations, etc.

The most common pattern: patient schedules an annual physical (CPT 99396 or similar, $0 cost-share). During the visit, they mention a new symptom ("my back has been bothering me"), which the doctor briefly addresses. The provider bills two codes: 99396 preventive AND 99213 office E/M for the back-pain conversation. The 99213 is now subject to copay/coinsurance. AHRQ and consumer groups have flagged this pattern as a common consumer-billing surprise.

Whether the dual-coding is appropriate is a documentation question — the chart needs to show that the diagnostic work was substantively separate from the preventive visit. If it doesn't, the patient can dispute the diagnostic charge.

How to spot it on a bill

• 01.You scheduled an annual/wellness visit and expected $0 out of pocket.
• 02.The bill shows two CPT codes for the same date: a preventive code (99381–99397 or G0438/G0439) AND an E/M code (99202–99215).
• 03.You owe an unexpected copay or coinsurance.
• 04.The visit summary doesn't mention significant separate diagnostic work.

What to write — ready-to-paste language

Replace the bracketed fields with your specific details. Send by certified mail with return receipt, or via the hospital’s patient portal if it offers documented messaging. Keep a copy.

I'm writing about the bill for the visit on [date]. I scheduled this as an annual preventive exam (CPT [preventive code]), which under ACA §2713 (45 CFR §147.130) my plan is required to cover at $0 cost-share for in-network preventive services. The bill also includes CPT [E/M code], which is being processed at my normal cost-share. Please review whether the medical record documents work substantively separate from the preventive visit. If the diagnostic code does not reflect work beyond the preventive exam, please remove it. If the dual-coding is justified, please send me the chart entry from this visit per HIPAA §164.524 so I can review the documentation supporting the separate diagnostic service.

This is a starting point, not legal advice. Your specific situation may warrant additional details. Our scan tool drafts this letter automatically with your bill’s specifics filled in.

CPT codes commonly involved

These codes often appear in bills affected by this pattern. Click through for the federal benchmark price on each.

• CPT 99213
• CPT 99214
• CPT 99395
• CPT 99396
• CPT 99397
• CPT G0438
• CPT G0439

Related scenarios

• Upcoded ER visit — when the level on the bill doesn't match the chart

  ER visits billed at a higher complexity level than the medical record supports are the most common billing-error pattern in the country. Federal coding rules let you dispute the level.

• Unbundled charges — when one procedure gets billed as several

  Federal coding rules (NCCI edits) explicitly prohibit billing certain combinations of CPT codes together. When you see them on your bill, the federal benchmark gives you grounds to dispute.

• Wrong place-of-service code — facility billing for a non-facility visit

  Place-of-service codes determine whether Medicare and most insurance pay the higher facility rate or the lower non-facility rate. A code mismatch can inflate a bill substantially.

• Modifier-25 abuse — separate E/M billed alongside a procedure

  Modifier 25 lets a provider bill an office visit alongside a procedure on the same day, but only when the visit is a 'significant, separately identifiable' service. The OIG has repeatedly flagged inappropriate use.

Common questions