New Patient Wellness Exam: CPT Code 9920*

Hi Everybody – looking for some advice here.

Situation: I recently moved from LA to San Diego and finally got in to get a physical at a new HCP in my new area. The HCP is a large outpatient network that is affiliated to one of the two major academic centers in the area. I have an HDHP and surprisingly, when I received my EOB and billing statement from the provider, I see that I owe $282 for the visit (haven’t hit my deductible yet), despite my plan specifically covering preventative care at no charge. The labs were all covered, except for a vitamin D panel (upsell, but fine). I’m a generally healthy individual with a few pre-existing conditions and was given one referral to a specialist here.

Questions:

Should a physical for a new patient be billed under CPT code 99204? This seems like a way for PCPs to charge patients and insurers with unusually high costs since physicals (to my understanding) get billed at lower rates. I also did not see the provider or MA for longer than 30 minutes, so even if this is an appropriate class of code, it should have been 99202 or 99203.

Am I better off disputing this with the provider or the insurer? It seems that I could ask the provider to re-bill under a code that would get covered by the insurance, or I could alternatively dispute with the insurer that this was preventative care (and maybe point to all the standard labs that were performed)

I’m hoping the discussion that spurs from this could be helpful for others…happy to provide more detail if helpful!